Please complete this form in its entirety and hit submit at the end. Begin by clicking Next below. If you have any questions regarding this attestation or South Country's compliance program, please email us at compliance@mnscha.org.

1. Distribution of Standards of Conduct and Compliance Policies and Procedures.

My organization has adopted either South Country’s or a comparable Code of Conduct and compliance policies and procedures which have been distributed to employees within 90 days of hire, upon revision, and annually thereafter.

2. General Compliance and Fraud, Waste, and Abuse (FWA) Training

My organization has completed adequate training to implement an effective compliance program designed to prevent, detect, and correct Medicare and Medicaid non-compliance, fraud waste and abuse, and address improper conduct in a timely and well-documented manner.

3. Exclusion Screening

My organization screens the OIG List of Excluded Individuals/Entities (LEIE), the Excluded Parties List System (EPLS, within the HHS System for Awards Management) database, and the Minnesota Department of Human Services (DHS) Excluded Provider Lists exclusion lists prior to hire or contracting, and monthly thereafter, for our employees and Downstream Entities.

4. Monitoring and Auditing Downstream Entities

My organization either doesn’t use Downstream Entities or uses Downstream Entities in connection with South Country programs and we monitor and audit their performance to ensure they are also in compliance with applicable Centers for Medicare & Medicaid Services (CMS) requirements.

5. Record Retention

My organization understands and agrees to maintain records and supporting documentation for a period of 10 years and will furnish evidence of the above to South Country or CMS upon request.

 6. Mechanism to Report FWA and Compliance Concerns

My organization has distributed a confidential FWA and compliance reporting mechanism to all employees and downstream entities.

7. Reporting FWA and Noncompliance

My organization has disclosed all instances of FWA and noncompliance including all instances of FWA and noncompliance from downstream entities.

By submitting this form, I hereby attest that the information contained herein is true, correct and complete and agree to complete this attestation on an annual basis.