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C/O: HealthSmart Management Services Organization, Inc.

Mailing: Post Office Box 6300, Cypress, CA 90630

Phone: (714) 947-8600; Fax: (714) 947-8708

INDUSTRY COLLABORATION EFFORT (ICE) MEDICARE ADVANTAGE

And MEDI-CAL GENERAL COMPLIANCE AND FRAUD, WASTE AND ABUSE TRAINING

ATTESTATION FORM.

Submission Due Date: Click here to enter a date.

Attestation Submission Instructions

The attestation form may be faxed or mailed or scanned and emailed to:

or faxed to (714) 947-8708

Vendor Name: Click here to enter text.

Submitting Organization: Choose an item.

(Such as MSO, TPA, if other than IPA/Medical Group or Hospital or Contractor)

Date Submitted: Click here to enter a date.

Principal Officer with Contract Signatory Authority:

Print Name: Click here to enter text.

Signature: ______

Please check (√) one or more of the following related to the annual training requirement:

ICE - Fraud, Waste, and Abuse (FWA) Compliance Training go to www.healthsmartmso.com

☐ I have completed the ICE MA General Compliance and Fraud, Waste and Abuse training for all employees, providers and contractors using the ICE Training documents. I also have integrated training into the new hire process and process to contract with new providers, pharmacies and contractors.

Date: Click here to enter a date.

☐ I have completed alternate equivalent MA General Compliance and Fraud Waste and Abuse Training for all employees, providers and contractors. I also have integrated that alternate training into the new hire process and process to the contract with new providers, pharmacies and contractors.

☐ I have completed alternate equivalent MA General Compliance Training for all employees, providers, pharmacies and contractor and separate Fraud Waste and Abuse training for employees and contractors who are not Medicare Providers. (The FWA training is deemed for Medicare Providers) I also have integrated that alternate training into the new hire process and process to contract with new providers, pharmacies and contractors.

☐ Other- Provide Explanation:

Click here to enter text.