36C79118R0022-005.docx

ATTACHMENT 3

ATTESTATION STATEMENT FOR SOLICITATION 36C79118R0022

_________________________ (name of vendor) hereby agrees and attests to for all facilities listed on Attachment 2 Facility List:

(A) Maintain Medicare certification and possess ESRD provider numbers for each facility. Maintain compliance with all applicable certification standards and standards of care delivered. Provide copies of certification as requested by the VA.

(B) Maintain compliance with 42 CFR, Parts 405, 410, 413, et al.; Conditions for Coverage for End Stage Renal Disease Facilities; Final Rule April 15, 2008.

(C) Maintain compliance with all applicable state and local regulations and requirements for dialysis care.

(D) Maintain employee certifications and records to include OSHA requirements, employee technical competency, evaluations, assessment and training and update, renew as necessary.

(E) Employees of the contractor are in compliance with VA privacy and security training requirements

(F) Contractors are compliant with Medicare testing guidelines and standards (equipment and environmental)

(G) Contractors will submit their claims electronically.

I certify that I have reviewed each Federal requirement indicated above and that all facilities listed on Attachment 2, Facility List are in compliance with the applicable requirements. I also certify that all facilities are Medicare certified and in compliance with all applicable certification standards and levels of care delivered. I will ensure all future revisions to Medicare’s compliance measure are incorporated at no cost to the Government.

Signature________________________

Name___________________________

Title_____________________________

Company Name___________________

Date ____________________________