Healthcare Revalidation Document

HEALTHCARE REVALIDATION DOCUMENT

Submission Date:   Revalidation Effective Date:

Provider / Organization Information

Business Entity Type: Individual/Sole Proprietor Corporation LLC Group Practice Other

Primary Contact for Revalidation

Practice Locations and Services

Insurance / Payer Enrollment Information

Enrollment Status: Enrolled Pending Terminated

Banking / EFT Authorization

I authorize the payer to initiate electronic funds transfers to the account identified below. The undersigned certifies that they are authorized to enroll this account for direct deposit and that the account information is correct.

Account Type: Checking Savings

Ownership and Control Disclosure

Provide the name, title, ownership percentage and identifying number (e.g., SSN/EIN) for any person or entity that has a five percent (5%) or greater direct or indirect ownership or control interest in the provider entity. Attach additional sheets if necessary.

Has there been any change in ownership, control, or managing employees since the last validated enrollment? Yes No

Attestation and Certifications

The undersigned authorized official certifies, under penalty of perjury and applicable law, that the information provided on this revalidation document and any attachments is true, correct, and complete to the best of their knowledge. The undersigned further certifies that:

1. All licensing, accreditation, and background information submitted is accurate and current;
2. The provider maintains all required credentials and documentation to perform services as represented;
3. No adverse actions, sanctions, or exclusions exist that would affect participation with payors unless disclosed herein;
4. The authorized official has the authority to execute this revalidation on behalf of the provider and to bind the provider to these statements.

I authorize the payer, its agents, and any authorized contractors to verify or obtain any additional documentation or information necessary to complete revalidation, including credentialing records, licensure, ownership documentation, and criminal background checks where permitted by law. This authorization expires on:

Acknowledgment of Penalties: I understand that knowingly making a false statement or omission in this revalidation document is punishable under applicable civil or criminal statutes and may result in revocation of enrollment, monetary penalties, and other sanctions.

HIPAA / Privacy Acknowledgment

By signing below, the authorized official acknowledges any protected health information submitted in support of this revalidation is provided for purposes directly related to payment and operations. The provider certifies that any disclosures are made in accordance with applicable privacy and security laws.

Consent to Release Information: I consent to release information as described above.

Supporting Documentation Checklist

The following items are included with this revalidation submission (check all that apply):

Current professional license copy Board certification Malpractice insurance declaration W-9 or tax document Other (see attachments)

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