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Exhibit 1

SAMPLE ATTESTATION FORMAT

The following is an example of an acceptable format for an attestation of provider-based compliance. CMS recommends that you place the initial page of the attestation on the official letterhead of the main provider if you elect to use this or any other format. Attestations should be submitted to your fiscal intermediary (FI) or Medicare Administrative Contractor (MAC) with a copy to your CMS Regional Office.

Please note that provider-based determinations under 42 CFR 413.65 in relation to hospitals are not made for the following facilities: ambulatory surgical centers (ASCs), comprehensive outpatient rehabilitation facilities (CORFs), home health agencies (HHAs), skilled nursing facilities (SNFs), hospices, inpatient rehabilitation units that are excluded from the inpatient prospective payment system for acute hospital services, independent diagnostic testing facilities furnishing only services paid under a fee schedule (subject to §413.65(a)(1)(ii)(G)), ESRD facilities, departments of providers that perform functions necessary for the successful operation of the providers but do not furnish services of a type for which separate payment could be claimed under Medicare or Medicaid (for example, laundry or medical records departments), ambulances, and RHCs affiliated with hospitals having more than 50 beds.

PROVIDER-BASED STATUS ATTESTATION STATEMENT

Main provider’s Medicare PTAN/CCN:

___________________________

(PTAN = Provider Transaction Access Number & CCN = CMS Certification Number. These should be the same.)

Main Provider’s National Provider Identifier (NPI):			___________________________
Main provider’s name (lbn):
	______________________			_____
Main provider’s address:	_______________________________________
	_______________________________________
Attestation Contact name:	___________________________________________
Contact Phone Number:	___________________________________________
Contact E-mail:	_______________________________________________
Provider-Based Facility/Organization’s name:			____________________________
Facility/Organization’s exact address:		_________________________________
(Include bldg. no., suite/room no., etc.)

_________________________________

The facility/organization became provider-based with the main provider on the following date:

____________


Facility/Organization’s Medicare PTAN, if there is one:		___________________________
Facility/Organization’s NPI, if there is one:	_________________________________

(Note: Many provider-based departments may not have an NPI separate from that of the main provider)

Is the facility/organization part of a multi-campus hospital?____________________________

Main Provider’s FI or MAC:

Is the main provider accredited? By whom?

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Exh 1 –Sample Attestation		Date

Exhibit 1		2
For Critical Access Hospitals
Is the main provider a critical access hospital (CAH)?	Y	N
If so, please read and certify the following:

There are now prohibitions against the acquisition or creation of off-campus provider-based facilities, including co-located facilities, by a CAH after January 1, 2008. Under 42 CFR §485.610(e), facilities that are provider-based, as defined in 42 CFR §413.65, or distinct part psychiatric or rehabilitation unit, as defined in 42 CFR §485.467, must be located more than a 35-mile drive (or, in the case of mountainous terrain or in areas with only secondary roads available, a 15-mile drive) from a hospital or another CAH. If a CAH does not meet these provisions, its provider agreement is subject to termination in accordance with the provisions of 42 CFR §489.53(a)(3), unless the CAH terminates the provider-based status of the off- campus and/or co-location arrangement.

On-campus facilities that are acquired or created after January 1, 2008, are exempted from this regulation, as are rural health clinics (RHCs) as defined in 42 CFR §405.2401(b).

Please complete A OR B below:

A._________ This facility satisfies the requirements of 42 CFR §485.610(e) because (please check all that apply):

______ It is an RHC, on-campus, and/or had provider-based status on or before

January 1, 2008.

______ It is located more than a 35-mile drive (or, in the case of mountainous

terrain or in areas with only secondary roads available, a 15-mile drive) from a hospital or another CAH.

______ This facility was “under development” prior to January 1, 2008. (Please

include a copy of the letter from the CMS Regional Office recognizing that plans existed prior to January 1, 2008, for the CAH to acquire or construct the provider- based facility or distinct part unit.)

--OR--

B._________ I understand that the facility does not meet the provisions of

42 CFR §485.610(e) and wish to attest to the provider-based status of this facility. I

further understand that treatment of this facility as provider-based makes the provider’s Medicare provider agreement as a CAH subject to termination.

For Other Entities:
Is the facility a Federally Qualified Health Center (FQHC)? Y	N

If so, and if the FQHC meets the criteria at section 413.65(n), it need not attest to its provider- based status. The provider-based rules do not apply to FQHCs that do not meet the criteria at section 413.65(n), and an attestation should not be submitted.

Is the facility a Rural Health Clinic (RHC)?Y N

If so, Medicare will not make a provider-based determination under 42 CFR 413.65 if the main provider has 50 or more beds or is otherwise eligible for the RHC upper limit payment exception.

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Exh 1 –Sample Attestation		Date

Exhibit 1

Please indicate if this attestation is adding, deleting, or changing previously submitted attestation information, including the effective date:

Add

Delete

Change

Effective Date

Please indicate the types of services furnished at the facility (please check all that apply):

1.Outpatient hospital services and supplies incident to a physician service

2.Outpatient hospital diagnostic services

3.Outpatient hospital therapy services, including any combination of occupational therapy, physical therapy, and/or speech-language pathology

4.Other (please specify)

I certify that I have carefully read the attached sections of the Federal provider-based regulations, before signing this attestation, and that the facility/organization complies with the following requirements to be provider-based to the main provider (initial ONE selection only):

1._____ The facility/organization is “on campus” per 42 C.F.R. §413.65(a)(2) and is in compliance with the following provider-based requirements (shown in the following attached pages) in §413.65(d) and §413.65(g), other than those in §413.65(g)(7). If the facility/organization is operated as a joint venture, I certify that the requirements under §413.65(f) have been met. I am aware of, and will comply with, the requirement to maintain documentation of the basis for these attestations (for each regulatory requirement) and to make that documentation available to the Centers for Medicare & Medicaid Services (CMS) and to CMS contractors upon request.

2._____ The facility/organization is “off campus” per 42 C.F.R. §413.65(a)(2) and is in compliance with the following provider-based requirements (shown in the following attached pages) in §413.65(d) and §413.65(e) and §413.65(g). If the facility/organization is operated under a management contract/agreement, I certify that the requirements of §413.65(h) have been met. Furthermore, I am submitting along with this attestation to the Centers for Medicare & Medicaid Services (CMS), the documentation showing the basis for these attestations (for each regulatory requirement).

If the provider-based facility is a department of a hospital, please describe the physical setting of the premises. For example, is the department in a building that houses other, freestanding, healthcare providers or suppliers? If so, describe how the hospital department is separated from these freestanding spaces.

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Exh 1 –Sample Attestation		Date

Exhibit 1

Please complete the following for on campus AND off campus facilities and organizations:

I attest that the facility/organization complies with the following requirements to be provider- based to the main provider (please indicate Yes or No for each requirement):

1.____ The department of the provider, the remote location of a hospital, or the satellite facility and the main provider are operated under the same license, except in areas where the State requires a separate license for the department of the provider, the remote location of a hospital, or the satellite facility, or in States where State law does not permit licensure of the provider and the prospective department of the provider, the remote location of a hospital, or

the satellite facility under a single license. If the provider and facility/organization are located in a state having a health facilities’ cost review commission or other agency that has authority to regulate the rates charged by hospitals or other providers, the commission or agency has not found that the facility/organization is not part of the provider.

2.____ The clinical services of the facility or organization seeking provider-based status and the main provider are integrated.

2a. ____ Professional staff of the facility or organization have clinical privileges at the

main provider.

2b. ____ The main provider maintains the same monitoring and oversight of the facility or

organization as it does for any other department of the provider.

2c. ____ The medical director of the facility or organization seeking provider-based status

maintains a reporting relationship with the chief medical officer or other similar official of the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the medical director of a department of the main provider and the chief medical officer or other similar official of the main provider, and is under the same type of supervision and accountability as any other director, medical or otherwise, of the main provider.

2d. ____ Medical staff committees or other professional committees at the main provider are

responsible for medical activities in the facility or organization, including quality assurance, utilization review, and the coordination and integration of services, to the extent practicable, between the facility or organization seeking provider-based status and the main provider.

2e. ____ Medical records for patients treated in the facility or organization are integrated into

a unified retrieval system (or cross reference) of the main provider.

2f. ____ Inpatient and outpatient services of the facility or organization and the main provider

are integrated, and patients treated at the facility or organization who require further care have full access to all services of the main provider and are referred where appropriate to the corresponding inpatient or outpatient department or service of the main provider.

3.____ The financial operations of the facility or organization are fully integrated within the financial system of the main provider, as evidenced by shared income and expenses between the main provider and the facility or organization. The costs of a facility or organization that is a hospital department are reported in a cost center of the provider, costs of a provider-based facility or organization other than a hospital department are reported in the appropriate cost center or cost centers of the main provider, and the financial status of

any provider-based facility or organization is incorporated and readily identified in the main provider’s trial balance.

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Exh 1 –Sample Attestation		Date

Exhibit 1

4.____ The facility or organization seeking status as a department of a provider, a remote location of a hospital, or a satellite facility is held out to the public and other payers as part of the main provider. When patients enter the provider-based facility or organization, they are aware that they are entering the main provider and are billed accordingly.

5.____ In the case of a hospital outpatient department or a hospital-based entity (if the facility is not a hospital outpatient department or a hospital-based entity, please record “NA” for “not applicable” and skip to requirements under number 6), the facility or organization fulfills the obligation of:

5a. ____ Hospital outpatient departments located either on or off the campus of the hospital

that is the main provider comply with the anti-dumping rules in §§489.20(l), (m), (q), and

(r) and §489.24 of chapter IV of Title 42.

5b. ____ Physician services furnished in hospital outpatient departments or hospital-based

entities (other than RHCs) are billed with the correct site-of-service so that appropriate physician and practitioner payment amounts can be determined under the rules of Part 414 of chapter IV of Title 42.

5c. ____ Hospital outpatient departments comply with all the terms of the hospital’s provider

agreement.

5d. ____ Physicians who work in hospital outpatient departments or hospital-based entities

comply with the non-discrimination provisions in §489.10(b) of chapter IV of Title 42.

5e. ____ Hospital outpatient departments (other than RHCs) treat all Medicare patients, for

billing purposes, as hospital outpatients. The departments do not treat some Medicare patients as hospital outpatients and others as physician office patients.

5f. ____ In the case of a patient admitted to the hospital as an inpatient after receiving

treatment in the hospital outpatient department or hospital-based entity, payments for services in the hospital outpatient department or hospital-based entity are subject to the payment window provisions applicable to PPS hospitals and to hospitals and units excluded from PPS set forth at §412.2(c)(5) of chapter IV of Title 42 and at §

413.40(c)(2) of chapter IV of Title 42, respectively. (Note: If the potential main provider is a CAH, enter “NA” for this item).

5g. ____ (Note: This requirement only applies to off campus facilities. This obligation

does not apply to services where there is no professional component to the hospital’s technical component charge, e.g laboratory, Physical Therapy,

Occupational Therapy, and Speech Pathology services). When a Medicare

beneficiary is treated in a hospital outpatient department or hospital-based entity (other than an RHC) that is not located on the main provider’s campus, and the treatment is

not required to be provided by the antidumping rules in §489.24 of chapter IV of Title

42, the hospital provides written notice to the beneficiary, before the delivery of services, of the amount of the beneficiary’s potential financial liability (that is, that the

beneficiary will incur a coinsurance liability for an outpatient visit to the hospital as well as for the physician service, and of the amount of that liability).

(1)____The notice is on that the beneficiary can read and understand.

(2)____If the exact type and extent of care needed is not known, the hospital furnishes

a written notice to the patient that explains that the beneficiary will incur a coinsurance liability to the hospital that he or she would not incur if the facility were not provider-

based, AND the hospital furnishes an estimate based on typical or average charges for visits to the facility, but states that the patient’s actual liability will depend upon the

actual services furnished by the hospital.

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Exh 1 –Sample Attestation		Date

Exhibit 1	6
(3)____If the beneficiary is unconscious, under great duress, or for any other reason is
unable to read a written notice and understand and act on his or her own rights, the
notice is provided before the delivery of services, to the beneficiary’s authorized
representative.
(4)____In cases where a hospital outpatient department provides examination or
treatment that is required to be provided by the antidumping rules at § 489.24 of
chapter IV of Title 42, the notice is given as soon as possible after the existence of an
emergency condition has been ruled out or the emergency condition has been
stabilized.

5h. _____ Hospital outpatient departments meet applicable hospital health and safety rules for

Medicare-participating hospitals in part 482 of this chapter (part 485 if the main provider is a CAH).

Please include a copy of your Medicare beneficiary coinsurance notice and a copy of the provider’s policy and procedures for completion of the notice as documentation for this

obligation of provider-based status.

For off-campus facilities, please complete the following:

In addition to the above requirements (numbers 1-5h), I attest that the facility/organization complies with the following requirements to be provider-based to the main provider as an off campus facility (please indicate Yes or No for each requirement):

6.____ The facility or organization seeking provider-based status is operated under the ownership and control of the main provider, as evidenced by the following:

6a. _____ The business enterprise that constitutes the facility or organization is 100 percent

owned by the provider.

6b. ____ The main provider and the facility or organization seeking status as a department of

the provider, a remote location of a hospital, or a satellite facility have the same governing body.

6c. ____ The facility or organization is operated under the same organizational documents as

the main provider. For example, the facility or organization seeking provider-based status is subject to common bylaws and operating decisions of the governing body of the provider where it is based.

6d. _____ The main provider has final responsibility for administrative decisions, final

approval for contracts with outside parties, final approval for personnel actions, final responsibility for personnel policies (such as fringe benefits or code of conduct), and final approval for medical staff appointments in the facility or organization.

7._____ The reporting relationship between the facility or organization seeking provider-based status and the main provider has the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and one of its existing departments, as evidenced by compliance with all of the following requirements:

7a. ____ The facility or organization is under the direct supervision of the main provider.

7b. ____ The facility or organization is operated under the same monitoring and oversight by

the provider as any other department of the provider, and is operated just as any other department of the provider with regard to supervision and accountability. The facility or organization director or individual responsible for daily operations at the entity--

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Exh 1 –Sample Attestation		Date

Exhibit 1

(1)____ Maintains a reporting relationship with a manager at the main provider that has the same frequency, intensity, and level of accountability that exists in the relationship between the main provider and its existing departments; and

(2)____ Is accountable to the governing body of the main provider, in the same manner as any department head of the provider.

7c. ____ The following administrative functions of the facility or organization are integrated

with those of the provider where the facility or organization is based: billing services, records, human resources, payroll, employee benefit package, salary structure, and purchasing services. Either the same employees or group of employees handle these administrative functions for the facility or organization and the main provider, or the administrative functions for both the facility or organization and the entity are (1) contracted out under the same contract agreement; or (2) handled under different contract agreements, with the contract of the facility or organization being managed by the main provider.

8._____ The facility or organization is located within a 35-mile radius of the campus of the potential main provider, except when the requirements in paragraph 8a of this section are met (please check below in the appropriate location if you qualify for the exemption):

8a. ____ The facility or organization is owned and operated by a hospital or CAH that has a

disproportionate share adjustment (as determined under §412.106 of chapter IV of Title

42)greater than 11.75 percent or is described in §412.106(c)(2) of chapter IV of Title 42 implementing section 1886(e)(5)(F)(i)(II) of the Act and is:

(1)____ Owned or operated by a unit of State or local government;

(2)____ A public or nonprofit corporation that is formally granted governmental powers by a unit of State or local government; or

(3)____ A private hospital that has a contract with a State or local government that includes the operation of clinics located off the main campus of the hospital to assure access in a well-defined service area to health care services for low- income individuals who are not entitled to benefits under Medicare (or medical assistance under a Medicaid State plan).

8b. ____ The facility or organization demonstrates a high level of integration with the main

provider by showing that it meets all of the other provider-based criteria and demonstrates that it serves the same patient population as the main provider, by submitting records showing that, during the 12-month period immediately preceding the first day of the month in which the attestation for provider-based status is filed with CMS, and for each subsequent 12-month period:

(1)____ At least 75 percent of the patients served by the facility or organization reside in the same zip code areas as at least 75 percent of the patients served by the main provider;

(2)____ At least 75 percent of the patients served by the facility or organization who required the type of care furnished by the main provider received that care from that provider (for example, at least 75 percent of the patients of an RHC seeking provider-based status received inpatient hospital services from the hospital that is the main provider); or

(3)____ If the facility or organization is unable to meet the criteria in (1) or (2) directly above because it was not in operation during all of the 12-month period described paragraph 8b, the facility or organization is located in a zip code area included among those that, during all of the 12-month period described in paragraph 8b, accounted for at least 75 percent of the patients served by the main provider.

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Exh 1 –Sample Attestation		Date

Exhibit 1

8c. ____ If the facility or organization is attempting to qualify for provider-based status under

this section, then the facility or organization and the main provider are located in the same State or, when consistent with the laws of both States, in adjacent States.

Note: An RHC that is otherwise qualified as a provider-based entity of a hospital that is located in a rural area as defined in § 412.62(f)(1)(iii) of chapter IV of Title 42, and has fewer than 50 beds as determined under §412.105(b) of chapter IV of Title 42, is not subject to the criteria in 8a and 8b above.

9.____ The facility or organization that is not located on the campus of the potential main provider and otherwise meets the requirements of 1-8 above, but is operated under

management contract, meets all of the following criteria (please respond to 9a - 9d if the facility is operated under a management contract; otherwise record “NA” for “not applicable”):

9a. ____ The main provider (or an organization that also employs the staff of the main

provider and that is not the management company) employs the staff of the facility or organization who are directly involved in the delivery of patient care, except for management staff and staff who furnish patient care services of a type that would be paid for by Medicare under a fee schedule established by regulations at Part 414 of

chapter IV of Title 42. Other than staff that may be paid under such a Medicare fee schedule, the main provider does not utilize the services of “leased'' employees (that is,

personnel who are actually employed by the management company but provide services for the provider under a staff leasing or similar agreement) that are directly involved in the delivery of patient care.

9b. ____ The administrative functions of the facility or organization are integrated with those

of the main provider, as determined under criteria in paragraph 7c above.

9c. ____ The main provider has significant control over the operations of the facility or

organization as determined under criteria in paragraph 7b above.

9d. ____ The management contract is held by the main provider itself, not by a parent

organization that has control over both the main provider and the facility or organization.

For facilities/organizations operated as joint ventures requesting provider-based determinations: In addition to the above requirements (numbers 1-5h for on campus facilities), I attest that the facility/organization complies with the following requirements to be provider- based to the main provider:

10.____ The facility or organization being attested to as provider-based is a joint venture that fulfills the following requirements:

10a. ____ The facility is partially owned by at least one provider;

10b. ____ The facility is located on the main campus of a provider who is a partial owner;

10c. ____ The facility is provider-based to that one provider whose campus on which the

facility organization is located; and

10d. _____ The facility or organization meets all the requirements applicable to all

provider-based facilities and organizations in paragraphs 1-5 of this attestation.

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Exh 1 –Sample Attestation		Date

Exhibit 1

*I certify that the responses in this attestation and information in the documents are accurate, complete, and current as of this date. I acknowledge that the regulations must be continually adhered to. Any material change in the relationship between the facility/organization and the main provider, such as a change of ownership or entry into

a new or different management contract, may be reported to CMS. (NOTE: ORIGINAL ink signature must be submitted. Attestation must be signed by an official to whom the organization has granted the legal authority to commit the provider to fully abide by the statutes, regulations, and program instructions of the Medicare program.)

Signed:__________________________________________

(Signature of Officer or Administrator or authorized person)

__________________________

(PRINT Name of signature)

Title :___________________________________________

(Title of authorized person acting on behalf of the provider)

__________________________

(Direct telephone number)

Date :__________________________________________

*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. § 1001).

Published: March 15, 2012

REM-517 – Provider Based Determinations,	Page 9 of 9	17049
Exh 1 –Sample Attestation		Date

Question	Answer
Form Name	Attestation Form Sample
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	attestation form filled sample, filled attestation form sample, attestation how fill, printable attestation forms

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