Form - COE - HomeCentris Healthcare

Certification of Eligibility to Participate in Federal Health Care Programs

Applicant Name: *

In which state do you work?

Maryland

Virginia

Pennsylvania

Certification

The Office of the Inspector General (“OIG”) may impose financial penalties against health care providers that employ or enter into contracts with excluded individuals or entities to provide items or services to federal program beneficiaries (section 1128(a)(6) of the Act; 42 CFR 1003.102(a)(2). Providers such as hospitals, nursing homes, home health agencies, and hospices may face exposure if they submit claims to a federal health care program for health care items or services provided, directly or indirectly, by excluded individuals or entities.
Individuals may be excluded from participation in federal health care programs for a number of reasons, including a Medicare/Medicaid fraud or abuse conviction, license revocation, or failure to repay a federal student loan.

If a health care provider arranges or contracts (by employment or otherwise) with an individual or entity who is excluded by the OIG from program participation for the provision of items or services reimbursable under such a federal program, the provider may be subject to fines up to $10,000 for each item or service furnished by the excluded individual or entity, as well as an assessment of up to three times the amount claimed and program exclusion may be imposed.  Furthermore, if an individual seeks employment with a Medicare/Medicaid participating provider, it could affect his/her opportunity for reinstatement at the conclusion of the exclusion period.

I certify I am not subject to exclusion or debarment under federal law or designated in a nurse aid or other professional registry as having a finding concerning abuse, neglect, or mistreatment of a patient or misappropriation of a patient’s property.

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