Annual Employee Compliance Certification Form

ANNUAL EMPLOYEE COMPLIANCE CERTIFICATION FORM

I certify that I have received and agree to read the TIFT REGIONAL MEDICAL CENTER (“Tift Regional”) Code of Conduct, the Compliance Program and Tift Regional policies and procedures.

I promise to comply with the Compliance Program, the Code of Conduct and Tift Regional policies and procedures and understand that compliance with these policies, principles and standards is a condition of my continued employment or association with Tift Regional. I understand that violation of these policies, principles or standards may lead to disciplinary action up to and including termination. I also understand that Tift Regional reserves the right to occasionally amend, modify or update the Compliance Program, the Code of Conduct and Tift Regional policies and procedures. I also understand that the Compliance Program, the Code of Conduct and Tift Regional policies and procedures are only statements of principles for individual and business conduct and do not, in any way, constitute an employment contract or an assurance of continued employment or association with Tift Regional.

I acknowledge that:

1. It is my responsibility to report any alleged or suspected violation of any laws, regulations, the Code of Conduct or the Compliance Program, to my Supervisor, the Helpline, or the Compliance Officer; and

2. Unless otherwise noted below, I am not aware of any possible violation of the Code of Conduct or the Compliance Program.

I further certify that:

1. Unless disclosed to the Director of Human Resources, neither I nor my immediate family: (a) have a financial relationship (compensation or ownership through debt or equity) either directly or indirectly with any entity that transacts business with Tift Regional; (b) own an interest in, receive compensation from or provide services to, any entity in competition with Tift Regional; or (c) conduct business not on behalf of Tift Regional by or with any Tift Regional vendor, supplier, contractor or agency;

2. I am not presently excluded, debarred, suspended, sanctioned, or otherwise ineligible to participate in any federal, state, local, or private healthcare program or plan, including, but not limited to, Medicare and Medicaid; and

3. I am not aware of any circumstance, including any investigative, legal or administrative action, that could jeopardize my ability to participate, without restriction or limitation, in any federal, state, or local healthcare program, including, but not limited to, the Medicare and Medicaid programs.

SIGNATURE:

Employee

NAME (Print):

POSITION/DEPARTMENT:

DATE:

Amended: June 16, 2003

KS\6405\00225 Administration\Compliance Program\Amended Employee Compliance Certification Form.doc