Medicaid Payments Provider Certification

I hereby agree to keep such records as are necessary to disclose fully the extent of services provided to individuals under the state’s Title XIX plan and to furnish information regarding any payments claimed for providing such services, as the state agency or Department of Health and Human Services may request.

Signature of Physician or Supplier

I certify that the services listed above were medically indicated and necessary to the health of this patient and were personally furnished by me, or by my employee under my personal direction.

Notice

This is to certify that the foregoing information is true, accurate, and complete. I understand that payment and satisfaction of the claim will be from federal and state funds. I further understand that any false claims, statements, or documents, or the concealment of a material fact, may be prosecuted under applicable federal or state laws.