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?I _(print full name of the physician/practitioner)___ , hereby attest that the medical record entry for ___(date of service)__accurately reflects signature/notations that I made in my capacity as ___(insert provider credentials, e.g. M.D.)__ when I treated /diagnosed the above listed Medicare beneficiary.

I attest that, to the best of my knowledge and belief, all information in the above referenced data reported is accurate and complete. I have personal knowledge that some of the information in the above referenced data reported is not accurate or not complete.

I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.?

In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.

This attestation is a legal and binding document and is fully enforceable in a court of competent jurisdiction.

The Signature Witnessing or Attesting certificate is used to determine that the signature appearing on a document is that of the person appearing before the Notary and named in the document.

Attestation is a kind of testimony or confirmation. It is customary to sign a deed, make a will or sign other written documents in the presence of a witness who also signs the document to attest to its contents and the authenticity of the party's signature.