VT Medicaid Enrollment Attestation

Name(Required)

Check if the answer to any of these is "Yes".(Required)

Are you currently engaged in the use of illegal drugs or any other chemical substances that would in any way impair your performance?

Do you have reason to believe that you pose a risk to the safety of any individual under your medical care, or are you unable to perform the functions of a healthcare practitioner in any way?

Has any action ever been taken against your professional liability coverage based on your history of medical practice?

Have you had an adverse professional liability action within the past 10 years?

Have you ever been charged, convicted or plead guilty of a felony or misdemeanor (excluding traffic violations)?

Have you ever been the subject of investigation by any healthcare organization or military agency, related to your performance of medical duties, for any action that qualifies as fraudulent activities?

Are you aware of any information being reported regarding your performance as a medical practitioner, to any public medical malpractice reporting agency?

Have you ever been under investigation by any state or federal regulatory agencies in the past 10 years?

Have you ever been convicted, or are you currently under investigation, for sexual harassment or any other legal misconduct in the past 10 years?

Has any action ever been taken against your federal or state-controlled substance certifications or authorizations?

Have you ever been sanctioned (as defined above) in any State or Federal program in the past 10 years?

Is the provider part of a provider or entity that is subject to the provisions contained in Section 6032 of the Deficit Reduction Act?

In accordance with 32 VSA §3113(b) I declare, under the pains and penalties of perjury, that I am not in good standing with respect to (or in full compliance with a plan to pay) any and all taxes due. If you are in good standing, select NO.

Has the provider been convicted of a criminal offense related to their involvement in any program under Medicare, Medicaid, or the Title XX services program since the inception of those programs?

Does this entity have an ownership or controlling interest in any subcontractor in which the disclosing entity has direct or indirect ownership as indicated above?

Have you ever been disciplined in any manner during your medical education?

Have you ever voluntarily withdrawn or terminated your medical education due to an investigation?

Have you ever chosen to terminate your board certification while under investigation?

Do you have or have you ever had an association with another provider that has been or is currently excluded by the HHS Office of Inspector General (OIG) from Medicaid, or CHIP?

Do you have or have you ever had an association with another provider that has had Medicare, Medicaid, or CHIP billing privileges denied, revoked, or terminated?

Has any action ever been taken against your medical privileges or any other associations, by any hospital, healthcare institution or governing board?

Have you ever voluntarily withdrawn your privileges based on any action by a hospital, healthcare institution or governing board?

Have you ever been terminated or not renewed your enrollment, or subject to any disciplinary action by any healthcare organization?

Do you have or have you ever had an association with another provider who currently has uncollected debt to Medicaid, CHIP, or Medicare?

Do you have or have you ever had an association with another provider that has been or is currently subject to a payment suspension under a federal health care program?

Has any action ever been taken against your license or certification, by any state or certification board in the past 10 years?

Have there been any changes to your license, registration or certification in the past 10 years?

Have you voluntarily surrendered your professional license or certification in lieu of disciplinary action?

NONE OF THESE

Consent(Required)

I agree(Required)

I certify that the information I have provided in response to these questions is true, complete, and accurate to the best of my knowledge. I understand that providing false, misleading, or incomplete information may result in denial or termination of Medicaid enrollment and may have legal or administrative consequences.

Consent(Required)

I agree(Required)

I understand that although Vermont Wellness Collaborative Inc. may complete and submit this information on my behalf, I remain personally responsible for the accuracy of the information provided and for promptly notifying Vermont Wellness Collaborative Inc. of any changes that may affect my Medicaid enrollment status.

Consent(Required)

I agree(Required)

I authorize Vermont Wellness Collaborative Inc. and its designated representatives to complete, submit, and manage my enrollment, revalidation, and related documentation with Vermont Medicaid on my behalf, including responding to required disclosure questions, uploading supporting documentation, and communicating with Vermont Medicaid or its contractors as necessary to facilitate enrollment.

Signature