Get Attestation Regarding Monitoring Of Exclusionary Databases Form

The Attestation Regarding Monitoring Of Exclusionary Databases Form is a crucial document that verifies a provider's compliance with monitoring exclusionary databases. This guide offers a step-by-step approach to ensure users successfully complete the form online with confidence and clarity.

Follow the steps to accurately fill out the form online.

1. Press the ‘Get Form’ button to access the form in your preferred online editor.
2. Complete the 'Provider Name' field by entering the official name of the provider or organization. Ensure the name matches the registration documents.
3. Fill in the 'Provider Address' fields with the complete address, including street, city, state, and ZIP code.
4. Enter the 'Phone #' field with the primary contact number for your organization.
5. Input the 'Provider Tax ID #' in the designated section to ensure accurate identification for tax purposes.
6. Indicate your attestation by selecting 'Yes' to confirm that the Provider has a policy in place requiring monthly monitoring against the exclusionary databases.
7. In the 'Print or Type the Name of the Person Signing Below' section, enter the name of the authorized person signing the document.
8. Specify the 'Title' of the individual signing the form, which should reflect their position within the organization.
9. If the provider is a legal entity, confirm that the signer is authorized to bind the Provider by signing in the provided area, and add the date in 'MM/DD/YYYY' format.
10. Lastly, for further processing, fill in the 'Name and Phone Number of Person Who Prepared Attestation' and then make sure to save, download, print, or share the completed form as necessary.

Complete your documentation online today to ensure compliance and smooth operations.