Attestation of Training Completion As a first tier

Attestation of Training Completion As a first tier, downstream or related entity, _______________ (Organization Name) attests that it has administered appropriate education and training for compliance and to detect, correct and prevent potential fraud, waste and abuse, as required by the Federal Register for 42 CFR Parts 422 and 423 of the Medicare Program, effective January 1, 2016. Your organization completed the education and training to comply with the requirement. The Compliance training and education was completed on ______________. The Fraud, Waste and Abuse training and education (if applicable) was completed on _____________. (If a date of completion is not provided, IMCare will verify Medicare enrollment to determine compliance. ) By signing below, you attest that your organization will furnish training logs and certifications from downstream entities upon request to IMCare and/or CMS to validate that training was completed. __________________ Print name of organization representative _______________ Organization _________________ Representative’s title ___________________________________ Signature Date signed This attestation is valid through Dec. 31 of the calendar year. Sign and return by mail, electronically (imcarecompliance@co. itasca. mn. us) or by FAX (218 -327 -5545)