Univeristy of Arizona Health Network
Compliance Program and
Fraud, Waste and Abuse Plan Attestation
This form verifies that the designated signer has received, read, understands, and has disseminated the Compliance Program, which includes the Code of Conduct, compliance policies and procedures and the Fraud, Waste and Abuse Plan (FWA), to all employees as well as their first tier, downstream and related entities (FDRs). The designated signer agrees that their organization is responsible to keep training documentation for their employees and FDRs. Only one attestation is required to be sent to UAHP for the designated signer’s organization.
Receipt and signature of this document is an acknowledgement of UAHP’s expectation that every employee, staff, as well as first tier, downstream and related entities (FDRs), subcontractors and agents (business partners), will abide by the terms under the Compliance Program, which includes the Code of Conduct, compliance policies and procedures and the Fraud, Waste and Abuse Plan.
Any questions regarding the Compliance Program or updates made to the Provider Manual or policies and procedures regarding compliance, Code of Conduct or FWA will be referred to UAHP.
** Sales Agents/Producers when completing the attestation please use your Name (as it appears on your AZDOI license)
** Agencies and MGA’s when completing the attestation please use your organizational Name (as it appears on the AZDOI license)
E-Sign
I hereby attest that the information contained herein is true, correct and complete.
Submission Date: 9/22/2017
Name: (as it appears on your AZDOI license) NPN  
 
Email: Phone: Fax:
E-Sign and Submit Form