Note: Yellow highlighted fields are required

This Attestation Form is required to be completed by (Contracted Entity name) in accordance with the State and Federal regulatory requirements and contracting provisions as set forth in the agreement(s) between Contracted Entity and Memorial Health Services (MHS) and its entities and affiliates (Seaside Health Plan, MemorialCare Medical Foundation, MemorialCare Medical Group, Long Beach Memorial Medical Center, Miller Children's and Women's Hospital, Orange Coast Memorial Medical Center, Saddleback Memorial Medical Center, Greater Newport Physicians). This annual attestation must be signed and returned to Memorial Health Services as soon as possible (no later than 30 calendar days) from the receipt date of the request).

Contracted Entity certifies compliance with State, Federal, and Memorial Health Services contracting requirements as set forth below:

1. Fraud, Waste and Abuse (FWA) & General Compliance (GC) Training.

Contracted Entity's employees (temporary and permanent) and subcontractors should receive CMS approved FWA and GC training within 90 calendar days of hire (or contracting in the case of subcontractors) and annually, thereafter. CMS approved FWA and GC Training shall include, but is not limited to, State and Federal Fraud and Abuse Laws (e.g. the False Claims Act), Anti-Fraud Plan from the CMS Medicare Learning Network (MLN) at or Contracted Entity's alternate equivalent FWA and GC Training. The alternative training must be integrated into the new hire process and when contracting with subcontractors or other entities.

Please indicate which of the following acceptable fraud, waste and abuse and general compliance training programs have been completed by your organization by filling in the completion date to the right of the training name.

The Medicare Learning Network (MLN) Provider Compliance module. Date Completed:
In-House fraud, waste and abuse and general compliance training. Date Completed:
Other: Date Completed:

Please indicate by checking ''Yes" or "No" whether your organization's in-house fraud, waste and abuse and general compliance training program covers the following topics:

Definitions of fraud, waste and abuse Yes  /  No
Overview of laws & regulations related to Medicare Advantage (Part C and Part D fraud, waste and abuse, including a brief description of main requirements and criminal & civil penalties related to each of the following:
  • Federal False Claims Act and State False Claims Act
  • Yes  /  No
  • Anti-Kickback Statute/Stark Law
  • Yes  /  No
  • HIPAA Privacy & Information Security Requirements
  • Yes  /  No
    Entities/individuals excluded from doing business with the Federal Government - OIG exclusion list Yes  /  No
    Obligations of the first tier, downstream, and related entities to have appropriate policies and l procedures to address fraud, waste, and abuse Yes  /  No
    Process for reporting to Memorial Health Services suspected fraud, waste and abuse in first tier, downstream, and related entities Yes  /  No
    Protections for employees of first tier, downstream, and related entities who report suspected fraud, waste and abuse Yes  /  No
    General Compliance:
  • Covering the role of the compliance officer and/ or the compliance committee
  • Yes  /  No
  • Code of Conduct
  • Yes  /  No
  • Ethical principles governing your organization
  • Yes  /  No
    Other matters set forth in the course available from the Medicare Learning Network (MLN) referred to above Yes  /  No

    2. Screening of Excluded Individuals.

    Contracted Entity and its employees and/or subcontractors are not sanctioned, debarred, suspended or excluded from participation in Medicare or Medicaid under Sections 1128 or 1128A of the Social Security Act. Contracted Entity has screened its employees and/or subcontractors as required by CMS prior to employment or contracting with them, and at least monthly, thereafter against the CMS required exclusion lists: DHHS Office of Inspector General (OIG) List of Excluded Individuals and Entities (LEIE) and the General Service Administration/System Award for Management (SAM) Excluded Parties Lists Systems (EPLS).

    3. Special Needs Plan Model of Care ("SNP MOC")

    The Centers for Medicare & Medicaid issued final regulations on Medicare Improvements for Patients and Providers Act of 2008, also known as MIPPA. As part of this regulation, the Special Needs Plan Model of Care requires implementation by January 1, 2010.

    The SNP Model of Care requires that all SNP members receive an initial Health Risk Assessment (HRA) within 90 days of enrollment, and that an Individualized Care Plan (ICP) be created for each member. The ICP will be developed and shared with the member, the PCP and any other parties involved in managing the member's care such as IPA case managers or social workers. The purpose is to encourage the early identification of the member's health status, and allow coordinated care to improve their overall health.

    4. Reporting Fraud, Waste, Abuse and Compliance Issues

    Memorial Health Services and Contracted Entities have a responsibility to report any alleged compliance, fraud, waste and abuse, and/or conflict of interest issues that involves Memorial Health Services. Contracted Entities may confidentially report a potential violation of our compliance policies or any applicable regulation by utilizing the following methods:

    Memorial Health Services Reporting

    • Memorial Health Services 24/7, 1-888-933-9044
    • Compliance Officer, 17360 Brookhurst Ave, Fountain Valley, CA 92708
    • E-mail:


    I hereby attest on behalf of Contracted Entity that it has complied with and will continue to comply with the certification elements listed above. I also attest that my organization will furnish, as applicable, sign-in sheets, participant rosters, training materials, certificates of completion and/ or documentation of Medicare Certification to verify training completion as well as participate in required audits.

    Principal Officer/Administrator with Contract Signatory Authority:

    Principal Name:   Principal Officer/Administrator
    Principal Email:
    Entity Address:
    Entity Tax ID:
    Date: 4/20/2021

    I acknowledge this is an electronic signature and that all information provided above is accurate and truthful to the best of my knowledge.
    I understand that my electronic signature on this attestation form has the same legal force and effect as a signature produced by
    non-electronic means.