Attestation Form - Provider Screening of Employees and Contractors.docx
DOCX document 14 KB Posted
- Attached to
- Chaplain Services
- Solicitation number
- 6100029089
- Issued by
- Chester County, Tharptown (uniontown) CDP, Pennsylvania
About this file
This document is an Attestation Form from the Pennsylvania Department of Military and Veterans Affairs Bureau of Veterans Homes regarding the Provider Screening of Employees and Contractors. The form requires the signatory to attest that all entities, contracted/subcontracted individuals assigned to provide services at the specified State Veterans Home during the given month under the specified Contract Number, have been properly screened. The signatory also agrees to notify the relevant State Veterans Home's Administrative Officer immediately if any assigned individuals or subcontractors become excluded or receive notification of proposed exclusion from any federally funded health care program.
The form does not provide any details about pricing terms, set asides, incumbents, funding requirements, or other salient information related to a contract opportunity. It solely focuses on the provider screening and notification requirements for personnel assigned to deliver services at the specified State Veterans Home under the referenced contract.
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Text version
DEPARTMENT OF MILITARY AND VETERANS AFFAIRS
BUREAU OF VETERANS HOMES
PROVIDER SCREENING OF EMPLOYEES AND CONTRACTORS ATTESTATION FORM
I attest that in accordance with the Pennsylvania Department of Welfare (DPW) Bulletin No. 99-11-05, the entities (contracted/subcontracted), and their assigned individuals (as listed below or under separate attachment), have been screened.
I also attest that this list represents all those individuals/entities assigned to provide services at the _________________________________________________ during the month of ____________________ under Contract Number _____________.
I agree to notify the relevant State Veterans Home’s Administrative Officer immediately if the entity or any assigned individuals or subcontractor of the entity become excluded, receive written or verbal notification of a proposed exclusion from any federally funded health care program, or any other action that could lead to exclusion of the entity or any employee or subcontractor of the entity.
Name: ____________________________________________ Title: _____________________________________________ Signature: _________________________________________ Date: _____________________________________________
File details come from the government source that posted it. Updated .