* *Name of FDR
* *Address
* *City
* *State(XX)
* *Zip
* *Tax Id
* *NPI

Medicare program requirements apply to First Tier, Downstream, and Related entities (FDRs) to whom MediGold has delegated administrative or health care service functions relating to its Part C and D contracts. To ensure those requirements are met, MediGold has developed a Compliance attestation that must be completed and submitted annually by each FDR entity to confirm compliance.

I attest to the following:

* *1. Standards of Conduct and Compliance Policies:
I have reviewed MediGold's FDR Manual which includes MediGold's Standards of Conduct and Compliance Policies. My organization has received, understands, and has complied with the requirement to provide the following to our employees upon hire and annually thereafter by:

MediGold's Standards of Conduct and compliance policies; or

Our organization's Standards of Conduct and compliance policies

* *2. Compliance with Medicare Requirements:

My organization complies with all statutes, regulations, Centers for Medicare & Medicaid Services (CMS) program specific requirements and any contractual obligations agreed to between my organization and MediGold.

* *3. OIG and GSA Exclusion Screening:

My organization currently performs exclusion screening prior to hiring or contracting and monthly thereafter to ensure no individual or entity is excluded from participating in federally- funded programs. If an individual or entity appears on the exclusion list, they will be removed from any work related directly or indirectly to federal health care programs

My organization does not currently perform exclusion screening prior to hiring or contracting and monthly thereafter. Within 60 days of submission of this attestation, and monthly thereafter, a check will be performed to confirm the employees and contractors are not excluded from participation in federally-funded programs. If an individual or entity appears on the exclusion list, they will be removed from any work directly or indirectly to federal health care programs

* *4. General Compliance, Fraud, Waste, & Abuse (FWA) Issues Reporting Mechanisms:
My organization maintains a confidential compliance & FWA reporting mechanism that has been distributed and is widely publicized for all employees and contractors within the organization. My organization encourages reporting potential compliance and FWA issues by:

Maintaining our own system for reporting or

Distribution of MediGold's anonymous 24-hour Integrity Hotline (1-866-477-4661)

* *5. Downstream Entities:

If my organization enters into a written arrangement with a third party to perform any services to fulfill our contractual obligations to MediGold, my organization monitors these entities to ensure they comply with all requirements listed herein

My organization does not utilize downstream entities

* *6. Offshore Sub-Contractors:

My organization does not utilize offshore subcontractors in connection with providing services to MediGold

My organization utilizes offshore subcontractors in connection with providing services to MediGold. I understand that I must print, complete, and mail the Offshore Sub-Contractor Attestation

I certify that I have authority to attest for the group or organization listed above. My organization understands and agrees to maintain supporting documentation for a period of ten years and will provide such documentation to MediGold or CMS upon request.

* *Name	(Adding your name on this line will serve as your electronic signature)
* *Title
* *Email
* *Phone(##########)
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