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Get Attestation Statement For Exclusion From Pps

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 personal knowledge and belief I attest that the responses on the attached prospective payment system PPS exclusion work sheet are true and correct and that name of PPS-Excluded Hospital or Unit currently meets and will continue to meet the applicable requirements for exclusion from PPS for the period beginning first day of hospital s fiscal year as set out in Subpart B of 42 CFR Part 412. I agree that if the hospital or unit fails to meet any of these requirements between the date of attestation and the first day of the hospital s fiscal year I will notify the Regional Office name and address of RO of the change immediately in order to permit a valid determination of distinct part status prior to the beginning of the fiscal year. 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 personal knowledge and belief I attest that the responses on the attached prospective payment system PPS exclusion work sheet are true and correct and that name of PPS-Excluded Hospital or Unit currently meets and will continue to meet the applicable requirements for exclusion from PPS for the period beginning first day of hospital s fiscal year as set out in Subpart B of 42 CFR Part 412. I agree that if the hospital or unit fails to meet any of these requirements between the date of attestation and the first day of the hospital s fiscal year I will notify the Regional Office name and address of RO of the change immediately in order to permit a valid determination of distinct part status prior to the beginning of the fiscal year.

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