DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Form Approved OMB No. 0938-0984 ELECTRONIC FILE INTERCHANGE ORGANIZATION (EFIO) CERTIFICATION STATEMENT By his/her signature(s) below, the authorized official(s) of___________________________________________ (hereinafter referred to as the electronic file interchange organization, or EFIO) legally binds the EFIO to full adherence to all of the following conditions: 1. I certify that the EFIO has the written legal authority to act on behalf of any and all providers for whom the EFIO submits information to CMS or its agent (hereinafter collectively referred to as the Enumerator). This legal authority includes the submission of the provider’s application for a National Provider Identifier (NPI) and, if agreed to between the EFIO and the provider, updates and changes to the provider’s NPI data, deactivations, and other information. 2. I certify that any and all data the EFIO submits to the Enumerator on behalf of a provider will be no more than 12 months old from the date the provider certifies to the accuracy of the data to be submitted on his/her/its behalf. 3. For those providers on whose behalf the EFIO submits an initial application for an NPI, I certify that the EFIO will promptly notify via letter or e-mail each provider of the latter’s newly issued NPI or, if applicable, the rejection of the latter’s application. I further certify that the EFIO will only disseminate a provider’s NPI for purposes permitted under Federal or State law. 4. In situations involving providers on whose behalf the EFIO submits a request to change the provider’s existing NPI information or to deactivate the provider’s NPI, the EFIO agrees to promptly inform the provider of the confirmation of the change. 5. I certify that each provider on whose behalf the EFIO submits a NPI application has informed the EFIO in writing that the provider’s information that will be submitted to NPPES is accurate and complete. This applies to the provider’s initial application for a NPI and, if agreed to between the EFIO and the provider, updates and changes to the provider’s NPI data, and deactivations. 6. I certify that the EFIO is duly licensed to conduct business in all States that require the EFIO to obtain such licensure prior to conducting business in that jurisdiction. 7. I certify that the EFIO will maintain records of all correspondence and communications between itself and all providers on whose behalf the EFIO acts in the submission of NPI data to the Enumerator, and will maintain all electronic files and records submitted to and received from the Enumerator in the course of acting on a provider’s behalf. I certify that the EFIO will maintain such records and files referred to in this paragraph for a period of 7 years, unless CMS prescribes a shorter period. I further certify that the EFIO will ensure that such records and files (including, but not limited to, the NPIs themselves) cannot be accessed by any person or entity not authorized under Federal or State law to review them. 8. I certify that the EFIO will fully and promptly cooperate with the Enumerator upon the latter’s request in all matters relating to the verification of any information submitted by the EFIO on behalf of any provider. This includes promptly contacting the provider at the Enumerator’s request to obtain clarification of the provider’s data. 9. I understand that the Enumerator, on an as-needed basis, reserves the right to require the EFIO to furnish to the Enumerator additional or clarifying information, such as written documentation, to confirm: (1) my authority or any EFIO representative’s authority to act on behalf of the EFIO, (2) the status of any agency relationship between the EFIO and a provider, and (3) the EFIO’s status as a legitimate business organization. I certify that the EFIO will furnish the Enumerator with the requested information in a prompt fashion. Form CMS-10175 (08/06) EF 09/2006 Page 1 American LegalNet, Inc. www.FormsWorkflow.com 10. I certify that the EFIO has adequate procedures and resources in place to promptly handle any and all issues, questions, and concerns raised by providers on whose behalf the EFIO is acting for purposes of submitting NPI data. 11. I understand that CMS reserves the right to examine for auditing purposes any and all records, files, agreements, etc., addressed in this certification statement, and in the EFIO’s possession, at any time for any reason related to the EFIO’s submission of NPI data on behalf of providers. I certify that the EFIO will fully cooperate with CMS in the conduct of such audits. 12. I certify that I have the legal authority to bind the EFIO to all of the terms and conditions of this certification statement and that I am a W-2 employee and/or owner of the EFIO. I also certify that any and all representatives of the EFIO registered with the Enumerator to submit NPI data to the Enumerator have the legal authority to act on the EFIO’s behalf in doing so. I agree to promptly notify the Enumerator of any change in any representative’s legal authority to submit NPI data to the Enumerator on behalf of the EFIO. 13. I certify that any and all information in any form submitted to the Enumerator by the EFIO is truthful and correct to the best of my knowledge. If I learn that any such information so submitted was not correct, I agree to notify the Enumerator of this immediately. I understand that any information submitted by the EFIO to the Enumerator that any EFIO representative knows or should have known to be false or misleading, or deliberately omits or conceals pertinent information from the Enumerator, the EFIO is subject to any and all penalties permitted under Federal law and State law. Form CMS-10175 (08/06) EF 09/2006 Page 2 American LegalNet, Inc. www.FormsWorkflow.com ATTENTION: READ THE FOLLOWING PROVISION OF FEDERAL LAW CAREFULLY BEFORE SIGNING. Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry, shall be subject to fines and/or imprisonment (18 U.S.C. Section 1001). To the best of my knowledge and belief, all data in this application are true and correct, and the governing body of the EFIO has duly authorized the signature of this document. First Authorized Official – Full Name (Print) Title/Position Telephone Number Legal Business Name of EFIO “Doing Business As ” Name of EFIO Business Address of EFIO First Authorized Official Signature Second Authorized Official – Full Name (Print) Title/Position Telephone Number Legal Business Name of EFIO “Doing Business As ” Name of EFIO Business Address of EFIO Second Authorized Official Signature According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-0984. The time required to complete this information collection is estimated to 3 hours per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Baltimore, Maryland 21244-1850. Form CMS-10175 (08/06) EF 09/2006 Page 3 American LegalNet, Inc. www.FormsWorkflow.com