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EXHIBIT 127 Rev. 61 Issued 07-23-10 Effective 07-23-10 Implementation 07-23-10 ATTESTATION STATEMENT FOR EXCLUSION FROM PPS FOR FISCAL YEAR BEGINNING DATE Date State Agency Director Name State Agency Name Address City State ZIP Code Dear State Agency Director This attestation must be signed by the Administrator/Chief Executive Officer of the hospital including hospitals with excluded units. ATTENTION Read the following carefully before signing. STATEMENTS OR ENTRIES GENERALLY Whoever in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies conceals or covers up by any trick scheme or device a material fact or makes any false fictitious or fraudulent statement or representations or makes or uses any false writing or document knowing the same to contain any false fictitious or fraudulent statement or entry shall be fined not more than 10 000 or imprisoned not more than five years or both. 18 U.S.C. Sec.1001 Based upon my per....

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Related content

SOM - Exhibit 127 - CMS
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KENNETH WELCH - Paed Uscourts TRANSPORT INTERNATIONAL - Paed Uscourts DOLORE - Eastern District Of Pennsylvania - Paed Uscourts 1 Rule 12(b)(6) States: (b) - Eastern District Of Pennsylvania - Paed Uscourts

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
DMCA Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
1-877-389-0141
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232