Healthcare Corporate Renewal Form

Healthcare Corporate Renewal Form

Corporate Legal Name:

I. CORPORATE IDENTIFICATION

State of Incorporation:    Date of Incorporation:

II. CONTACT & LOCATION

III. AUTHORIZED REPRESENTATIVES

Provide the names and titles of individuals authorized to execute documents on behalf of the corporation. Attach corporate resolution if authorization differs from listed officers.

IV. INSURANCE, LICENSING, AND CREDENTIALS

V. OWNERSHIP & BENEFICIAL INTEREST

Does any individual or entity own 5% or more of the corporation? Yes No

Have there been any changes in ownership, management, corporate structure, or operations since the last renewal? Yes No

VI. COMPLIANCE & CERTIFICATIONS

By signing below, the authorized representative certifies under penalty of law that the information provided in this renewal and accompanying documentation is true, complete, and accurate. The corporation affirms that it remains duly organized and in good standing under applicable laws, that it maintains required licenses and insurance, and that no owner or controlling party is currently debarred, excluded, or otherwise ineligible to participate in federally funded healthcare programs.

The corporation agrees to notify the recipient organization in writing within thirty (30) calendar days of any material change to ownership, control, accreditation status, licensure, insurance coverage, or any adverse legal or regulatory action affecting the corporation. Failure to disclose material changes may result in termination of contractual relationships, recovery of payments, and other remedies permitted by law.

The corporation certifies that it has implemented and maintains appropriate administrative, physical, and technical safeguards to protect individually identifiable health information, and that it will comply with applicable privacy and security obligations when handling protected health information.

Certification: I certify the above statements are accurate and complete.

VII. ATTACHMENTS CHECKLIST

Please indicate which documents are attached to this renewal. Missing required attachments may delay processing.

Articles of Incorporation

Corporate Resolution Authorizing Signatory

Certificate of Good Standing / Equivalent

Evidence of Professional Liability Insurance

Other Supporting Documents (list below)

VIII. AUTHORIZATION PERIOD

Renewal Effective Date:    Renewal Expiration Date:

IX. REPRESENTATIONS, WARRANTIES, AND INDEMNIFICATION

The corporation represents and warrants that it is authorized to enter into agreements and to perform obligations under any resulting contract; that all statements made in this renewal are true and complete; and that it will indemnify, defend, and hold harmless the recipient organization from any losses, liabilities, or claims arising from false statements, breach of representations, or the corporation's negligent or willful acts or omissions.

The corporation further acknowledges that the recipient organization may, at its discretion, verify submitted information and that discovery of material misrepresentation may result in administrative remedies including denial of renewal, termination of participation, and referral to regulatory authorities.

X. SIGNATURE

The undersigned certifies that they are an authorized officer, partner, owner, or agent of the corporation and that they have the authority to bind the corporation to the statements and commitments contained in this renewal.

Certification statement: I declare under penalty of perjury that the information provided in this Healthcare Corporate Renewal Form and attachments is true, correct, and complete to the best of my knowledge. I acknowledge that intentional misrepresentation may subject the corporation and myself to civil and criminal penalties as provided by law.

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