General Information - All Providers Complete ver. 9-2013 page 1

VNSNY CHOICE Institutional/Ancillary/Facility Provider Network Application

This application is intended for institutional and ancillary providers, including: Vendors and Suppliers (medical equipment and supplies) Facilities (hospitals, nursing homes, dialysis centers, rehab centers, etc.) Community based organizations Service providers (transportation, meals, day care)

Instructions:

Please complete the sections applicable to the service(s) you intend to provide. Required documents—as specified by service type—must be submitted with the

application.---- Applying as (check applicable boxes): ----

Transportation—Car/Livery Service Skilled Nursing Facility (SNF)/Nursing Home

Transportation—Ambulette Laboratory

Transportation—Ambulance Federally Qualified Health Center (FQHC)

Social Adult Day Care Diagnostic and Treatment Center (DTC)

Medical Adult Day Care Community Health Center/Clinic (non-FQHC)

Chores/Housekeeping Ambulatory Surgery Center (ASC)

Pest Control/Extermination Services Radiology Center

Durable Medical Equipment (DME) Supplier Dialysis Center

Medical Supplies Vendor Infusion/IV Therapy provider

Prosthetic/Orthotic Supplier Medicare Certified Home Health Agency (CHHA)

Outpatient Rehabilitation (PT/OT/ST) facility State Licensed Home Care Services Agency (LHCSA)

Home Delivered Meals (“Meals on Wheels”) Personal Care Service Agency

Hospital

Other (specify):

Plan Use ONLY. Participation:

Medicare Plan

Managed Long Term Care (MLTC)

SelectHealth Medicaid

FIDA Plan

Staff:

General Information - All Providers Complete ver. 9-2013 page 2

Institutional/Ancillary Provider Network Application

ORGANIZATION INFORMATION

[All Providers Complete]

Organization’s Legal Name: Known As or DBA Name:

Street Address: City, State, Zip

County: Telephone No.:

(for publication in directory)

Name of Owner or Sponsoring Agency: Name of Administrator or Program Director:

Contact Person for Additional Information: Title: Telephone No.: Fax No.: Email Address: Website: Federal Tax ID No.: Medicaid Provider No.: Medicare Provider No.: NPI:

CORPORATE OFFICE address, if different from facility:

Address

City, State Zip

REMITTANCE INFORMATION: MUST MATCH IRS REGISTERED W9LEGAL NAME TO BE INPUTTED ON LINE 1, DBA IF APPLICABLE ON LINE 2

Checks Payable To: Mailing Address

City, State Zip

General Information - All Providers Complete ver. 9-2013 page 3

[All Providers Complete]

What is the organization’s geographic service area? Check all counties in which you provide services.

New York City Bronx Kings (Brooklyn) New York (Manhattan) Queens Richmond (S.I.)

NYC Suburbs Nassau Suffolk Westchester

Hudson Valley Dutchess Orange Putnam Rockland Sullivan Ulster

Please specify any limitations on your services within the counties you service: Capital Region Albany Columbia Greene Rensselaer Saratoga Schenectady Warren Washington

Upstate New York

Allegany Broome Cattaraugus Cayuga Chautauqua Chemung Chenango Clinton Cortland Delaware Erie Essex Franklin

Fulton Genesee Hamilton Herkimer Jefferson Lewis Livingston Madison Monroe Montgomery Niagara Oneida Onondaga

Ontario Orleans Oswego Otsego St. Lawrence Schoharie Schuyler Seneca Steuben Tioga Tompkins Wayne Wyoming Yates

Organization’s Hours of Operation* (the times open for patient/client/customer service) If multiple shifts, indicate times for both:

Monday Friday Tuesday Saturday Wednesday Sunday Thursday

Capacity (if applicable):

Languages spoken by staff:*

Americans With Disabilities Act Information* Does your staff have the ability to communicate with the visually impaired? Yes No Does your staff have the ability to communicate with the hearing impaired? Yes No Is your facility wheelchair accessible? Yes No

General Information - All Providers Complete ver. 9-2013 page 4

[All Providers Complete]

LICENSURE AND ACCREDITATION

1. Is the organization licensed by the New York State Dept of Health? Yes No Not Applicable Type of License:

Effective Date:Expiration Date:

Date of most recent survey:Were there any deficiencies? Yes No

(if Yes, attach copy of corrective action plan with letter of acceptance by NYSDOH)

2. Is the organization accredited? Not Accredited Joint Commission CHAP ACHC Other (specify):

Effective Date: Expiration Date: Date of most recent survey:Services accredited for:

3. Does the organization include any lines of business that require thecollection of sales tax in the State of New York? Yes* No

*If Yes, has the organization registered to collect New York State andLocal sales and compensating use taxes? Yes** No

**If Yes, provide the sales tax ID number

ORGANIZATION BACKGROUND

4. Does your organization have any financial interest in the Visiting NurseService of New York? If Yes, please explain on a separate sheet. Yes No

5. Please check all of the terms below which apply to your organization: Non-profit Organization Small Business Minority Business Women-Owned Business

6. Within the past five (5) years, has the organization, any affiliate (including a wholly or partially owned subsidiary), anypredecessor company or entity, any owner of 5.0% or more of the firm’s shares, any director, officer, partner orproprietor or any employee alleged to have been acting on the part of the organization been the subject of any of thefollowing (respond to each question and describe in detail the circumstances of each affirmative answer; attachadditional page if necessary)?

a) Medicare or Medicaid sanctions (If yes, attach a copy of corrective action plan) No Yes b) a civil or criminal investigation of the New York State Ethics Commission involving a

violation(s) of Section 73 and Section 74 of the Public Office Law? No Yes

c) a criminal investigation, indictment, or judgment of conviction for any business-relatedconduct constituting a crime under state or federal law?

No Yes

d) a federal or state suspension, revocation of license or debarment? No Yes e) a State Labor Law violation deemed willful? No Yes f) any other federal or state citations, notices, violations orders, pending administrative

hearings or proceedings, or determinations of a violation of any labor law or regulation? No Yes

Yes No has this facility had or does it current;y have pending any legal actions against it?g)

General Information - All Providers Complete ver. 9-2013 page 5

[All Providers Complete]

CONTRACTING EXPERIENCE

7. Provide the following information about contracts your organization currently has with governmental or private entities.

7a. Organization is a participating provider in the NY State Medicaid program Yes No Not Applicable

7b. Organization is a Medicare provider Yes No Not Applicable

7c. Indicate other managed care/health insurance companies with which you have contracts (list below):

7d. Contracting reference (entity with which organization has a contract/provides services):

Agency Name: Address: City, ST Zip: Telephone: Fax: Contact Name: Title: How long affiliated? Summary of Services Provided:

7e. Additional contracting reference (entity with which organization has a contract/provides services): (if you are a participating provider in the New York State Medicaid program, you do NOT have to complete this 2nd reference portion)

Agency Name: Address: City, ST Zip: Telephone: Fax: Contact Name: Title: How long affiliated? Summary of Services Provided:

8. Does the organization subcontract any of its services to another entity? Yes No If yes, please attach a list of subcontracted services and the name of the organization(s) providing those services.

OPERATIONS AND SERVICES

Complete the entire section(s) applicable to the service(s) you provide.

Transportation - Page 1 of 1 ver. 9-2013

TR-1. If operating in New York City: Are you registered with the NYC Taxi and Limousine Commission? Not Applicable Yes No If Yes, please indicate Base License number in TR-2 below. If No, please explain below:

TR-2. NYC Taxi & Limousine Commission Base License No.:

TR-3. Are you registered with the NY State Dept. of Transportation (DOT)? Yes No If Yes, please provide DOT No.

TR-4. The following information is needed in order to be eligible to receive orders from VNSNY CHOICE’s electronic transportation ordering system

TR-4a. Do you have internet service available throughout the day to be able to log-in to a VNSNY CHOICE website to check online orders?

Yes No

TR-4b. Computer hardware is Pentium 4 or higher, 1 gb RAM or more, 17” monitor or larger? Yes No TR-4c. Computer software is Windows XP or higher, Internet Explorer 7 or higher? Yes No

TR-4d. Estimated hourly capacity (# of trips):

TR-4e. Primary person accessing VNSNY CHOICE Order System: Position: Telephone: Unique Email Address:

TR-4f. Secondary person accessing VNSNY CHOICE Order System: Position: Telephone: Unique Email Address:

CAR SERVICE

TR-5. No. of Vehicles: TR-6. Vehicles are: Company-owned fleet Driver-owned Other:

AMBULETTES (Must be NYSDOH Medicaid Program Participating)

TR-7. No. of Vehicles: TR-8. High Top Vehicles? Yes* No *If yes, how many? TR-9. Hydraulic Lifts or Ramps? Yes* No *If yes, how many? TR-10 Total Number of Ambulettes: TR-11. 2-man Assists? Yes No

AMBULANCE

TR-12. No. of Vehicles:

TRANSPORTATION PROVIDERS ONLY

Adult Day Care - Page 1 of 4 ver. 9-2013

Social Adult Day Care Medical Adult Day Care SOCIAL & MEDICAL ADULT DAY CARE PROVIDERS ONLY

For applicants with multiple sites, please complete separate pages for each site.

Site Name:

Address:

Telephone:

Organization’s Hours of Operation (the times open for patient/client service) If multiple shifts, indicate times for both:

Monday Friday Tuesday Saturday Wednesday Sunday Thursday

Languages spoken by staff:

Americans With Disabilities Act Information Does your staff have the ability to communicate with the visually impaired? Yes No Does your staff have the ability to communicate with the hearing impaired? Yes No Is your facility wheelchair accessible? Yes No

SD-1. Is the Adult Day Care program conducted: On-Site Off-Site If Off-Site, provide address:

SD-2. The Adult Day Center has a current Certificate of Occupancy, and follows all applicable city, town, and state building and fire codes. Yes No If NO, credentialing may not proceed.

SD-3. The Adult Day Center is currently open and operating: Yes No If NO, scheduled opening date:

SD-4. Total number of members per day that the program can accommodate: SD-5. Current attendees per shift/day:

Staffing SD-6. At least annually, do you assess and document the health status of each staff person who may or will have contact

with participants to ensure that he or she is free from any health impairment that is of potential risk to others or that may interfere with the performance of his or her duties? Yes No

SD-7. Do you require each staff person who may or will contact with participants to have a PPD (Mantoux) skin test for tuberculosis prior to employment and no less than every two (2) years, thereafter? Yes No

Adult Day Care - Page 2 of 4 ver. 9-2013

SD-8. Composition of professional and paraprofessional (aides) staff, including paid and non-paid; full and part-time. How Many Staff? Responsibilities (mark a to indicate those that apply)

Job Titles

Full-time ( # )

Part-time ( # )

Adm

inistrative

Activities

Food Service

Personal Care

Supervision & M

onitoring

Maintenance &

Upkeep

Other (specify)

SD-9: Do you provide staff with any of the following training?

New staff orientation. If YES, check those that apply: Orientation to the Program Provider, Community and the Program Itself Working with the Elderly Participants’ Rights Safety and Accident Prevention Other: _________________________________

____________________________________________________________________________________________

Supplementary service staff orientation (completed prior to delivery of adult day care services). If YES, check those that apply:

Orientation to Personal Care Skills Body Mechanics Behavior Management Other: _________________________________ None (Please explain):___________________________

______________________________________________________________________________________________

Additional service staff training (completed within 3 months of being assigned to provide social adult day care services). If YES, how many hours: ________ Check those that apply:

Socialization Skills and Activities Supervision and Monitoring Personal Care (taught by an RN) The Family and Family Relationships Mental Illness & Mental Health CPR Other: ________________________ None (Please explain):____________________________________

_____________________________________________________________________________________________

Adult Day Care - Page 3 of 4 ver. 9-2013

Annual retraining/In-service training. If Yes, how many hours per year:_______ Topics covered or intended to be covered:

SD-10: What is the minimum number of staff with the participants during the program session?: ________ SD-10a: What is the maximum ratio of staff to participants during the program session?__________

Services

SD-11. Program serves clients with (check those which apply): Physically Frail Dementia (indicate levels): Mild Moderate Severe

SD-12. List specific conditions that you serve, e.g. incontinence, people who are wheelchair-bound , etc.

SD-13. What type of personal care do you provide? (check all that apply below) Toileting Ambulation Transferring Feeding/Eating Bathing Dressing Grooming Prompting participants for self-administration of medications Routine Skin Care Using supplies and adaptive and assistance devices Changing simple dressing

SD-14. Please attach a copy of the program’s recent Calendar of Events. If more than one shift is offered, please provide calendars for all shifts. (minimum of 2 structured activities per shift)

SD-15. Number of hours of structured programming per day:

Transportation SD-16. Transportation for program participants (check all that apply): Not provided Provided by this organization Provided by a subcontractor* *If provided by a subcontractor, specify transportation company name and address:

SD-16a. Can wheelchairs be accommodated in transportation? Yes No

SD-17. Is an escort provided to accompany attendees on transport? Yes No SD-18. Do participants go on program-sponsored off-site trips?

If Yes, please describe: ______________________________________ Yes No

Policies and Procedures SD-19. Do you have a participant bill of rights or similar document? Please attach a copy. Yes No

SD-20. Do you have a written policies and procedures? Yes No Please check off all areas covered in the written policies and procedures:

Incidents or accidents Complaints Emergency preparedness/disaster plan Participant Eligibility (please attach) Admission and Discharge Service Plan (please attach) Staffing Plan, including Paid and Volunteer Staff Participants Rights Services Delivery Program Self-Evaluation Records and/or record-keeping Confidentiality Compliance

Other(s):

Adult Day Care - Page 4 of 4 ver. 9-2013

SD-21. Do you conduct a self-evaluation at least annually of your administrative, fiscal, and program operations?

Yes No

FOOD at the Day Care Site

SD-22. Do you provide: Meals. If yes, are they: Do you provide: Snacks. If yes, are they:

Hot Cold (check both if applicable) Hot Cold (check both if applicable)

SD-23. What time are the meals and snacks served: SD-24. Are the meals prepared: On-site Off-site (Brought in) SD-25. Does a nutritionist oversee/approve the menu? Yes No SD-26. Do you participate in the USDA Child and Adult Care Food Program? Yes No SD-27. For NYC providers: Do you get meals from the New York City Dept.

for the Aging (DFTA) Home Delivered Meals program? Yes No

SD-28. For providers outside of NYC: Do you get meals from a county or other governmental-sponsored agency?

Yes No

SD-29. Do you have a NYCDOH Food Service Establishment Permit? Yes No SD-30. Are you able to accommodate special dietary needs?

If yes, please specify below: Yes No

Low salt Diabetic Chopped / pureed Other:

Record Keeping SD-31. Does your record-keeping documentation include?:

Administrative and financial records Participant personal records, including identifying emergency, and medical information including physician name,

diagnosis, and medications Service records for each participant, including the individual assessment, the service plan and documentation of

the delivery of services SD-32. Attach a copy of a blank assessment and care plan. SD-33. Are participant records maintained in a secure place? Yes No SD-34. How do you track attendance at your site? SD-35. How do you track patients who use transportation to and from your site? SD-36. Do you subcontract any services to another entity? Yes (If YES, please describe below): No

SD-37. Do you provide any services for caregivers? Yes (if YES, please describe below) No

Home Delivered Meals (MOW) or Chores - Page 1 of 1 ver. 9-2013

HOME DELIVERED MEALS PROVIDERS ONLY MW-1. What meals are provided?

MW-2 Are meals prepared on site? Yes No If No, indicate name of caterer(s):

MW-3. Please indicate any special meals provided, e.g. Kosher, vegetarian, Chinese, Spanish, etc.

MW-4. For NYC providers, is the program funded by the NYC Dept. for the Aging (DFTA)? Yes No n/a If Yes, how many slots are funded by DFTA:

MW-5. For NYC providers, are you in compliance with DFTA’s Quality Assurance Guidelines? Yes No n/a Is the program funded by City Meals on Wheels? Yes No n/a

MW-6. Does the program have other funding sources? Yes No If Yes, please list below:

MW-7. How many staff members are involved in the coordination of this program?

CHORES/HOUSEKEEPING PROVIDERS ONLY CH-1. Please check all of the services below which your organization can provide:

Light duty cleaning Heavy duty cleaning Chores/shopping Carpet cleaning Mattress cleaning Laundry Furniture steam cleaning Furniture removal & disposal Rodent and bug extermination services Bed bug treatment

Home Health Agencies - Page 1 of 1 ver. 9-2013

Make sure you have indicated accreditation information in the appropriate prior section of this application!

HOME HEALTH AGENCIES ONLY

In addition to accreditation information, provide proof of: o CHHA--Participation in Medicare o LHCSA--Participation in Medicaid

HH-1. Please check all of the services below which your organization can provide:

Nursing Care Complex Wound Care Home Infusion Medical Social Services

Physical Therapy Occupational Therapy Speech Therapy

Home Health Aides Personal Care Workers

Other: HH-2. Do you have a licensed training program? Yes No

HH-3. Are employees bonded? Yes No

HH-4. Indicate any special areas of expertise or service you provide (check all that apply):

Alzheimer’s Behavioral Health Cardiac Care Difficult to Serve Client

Live-In Services Pediatric Care Rehab Services Traumatic Brain Injury

Other: HH-5. Home health aide/personal care worker timekeeping done by:

Paper duty sheets Telephonic login system Other:

Radiology Centers - Page 1 of 1 ver. 9-2013

RADIOLOGY CENTERS ONLY

Make sure you have indicated accreditation information in the appropriate prior section of this application!

For multiple sites, please copy this page and complete one for each site. RA-1. Please check all of the services below which your organization can provide:

X-ray CT MRI PET Scan Fluoroscopy

EMG IVP EKG Echocardiography Mammography

Ultrasound MRA PET Holter Monitoring Myelography

PET-CT CCTA CTA Nuclear Cardiography Arthrography

Nuclear Medicine Doppler Studies Bone Densitometry

Breast MRI & MR Guided Breast Biopsy Other:

Site Name: Known As or DBA Name:

Street Address: City, State, Zip

County: Telephone No.:

(for publication in directory)

Hours of Operation (the times open for patient service)

Monday Friday Tuesday Saturday Wednesday Sunday Thursday Capacity (if applicable):

Languages spoken by staff:

Americans With Disabilities Act Information

Does your staff have the ability to communicate with the visually impaired? Yes No Does your staff have the ability to communicate with the hearing impaired? Yes No Is your facility wheelchair accessible? Yes No

Facility / Institutional All Other - Page 1 of 1 ver. 9-2013

HOSPITALS CLINICAL REFERENCE LABORATORIES INFUSION VENDORS AMBULATORY SURGERY CENTERS DIALYSIS CENTERS DIAGNOSTIC & TREATMENT CENTERS/CLINICS OUTPATIENT REHABILITATION CENTERS DME/MEDICAL SUPPLIERS PROSTHETIC & ORTHOTIC VENDORS FQHCs HOSPICES

Make sure you have indicated accreditation information in the appropriate prior section of this application!

In addition to accreditation information, provide proof of:

Participation in Medicare Participation in Medicaid Operating Certificate CLIA Certification (Laboratories)

Attach list of sites, e.g. ambulatory care centers, patient service centers (Hospitals, Laboratories)

Nursing Home/SNF - Page 1 of 2 ver. 9-2013

SKILLED NURSING FACILITY (SNF) / NURSING HOMES ONLY

Make sure you have indicated accreditation information in the appropriate prior section of this application!

NH-1. Check all of the following treatments, procedures, and programs that the facility can accommodate: Skin / Ulcer treatments:

Pressure reducing devices Turning and positioning program Nutrition or hydration interventions Ulcer care Surgical wound care Application of non-surgical dressings Negative pressure therapy (Wound Vac)

Other Special Services: IV Therapy Transfusion Dialysis Hospice Care / Palliative Care Respite Care Nasal Gastric Tube Isolation or quarantine from active infectious diseases

Respiratory Treatments: Oxygen therapy Suctioning Tracheostomy Care Ventilator or respirator Bi Pap / CPAP

Cancer Treatments: Chemotherapy Radiation therapy

Special Programs: Traumatic Brain Injury Program Bariatric Program Alzheimer's / Dementia Program Wandering Unit Younger Adults Program

The information below will be helpful in determining nursing home placements: NH-2. Transfer agreements with which hospitals:

NH-3 Specialty/ethnic foods offered (if any):

NH-4. Facility’s Religious affiliation, if any: NH-5. Religious services offered on site (specify):

NH-6. Resident Council: Yes No NH-7. Family member sleepover allowed? Yes No NH-8. Family Council or Caregiver Support Group: Yes No NH-9. Visitor’s parking spaces available: Yes No

NH-10. Any special transportation available to the facility for visitors:

NH-11. Public transportation available nearby (specify):

NH-12. Ambulette/Ambulance providers utilized:

NH-13. List any medical service vendor, or other contract arrangements the facility maintains, e.g. laboratory, radiology)

Nursing Home/SNF - Page 2 of 2 ver. 9-2013

NH-14. Key Contacts at Nursing Home / SNF:

Position Name Telephone Fax Email

Administrator

Director, Admissions

Director, Social Work

Director, Patient Accounts

Director, Nursing

Director, Quality Management

Responsible for Medicaid Recert.

General Information - All Providers Complete Page 6 ver. 9-2013

[All Providers Complete]

ATTESTATION

I hereby affirm and represent that all statements and information contained in this application are true to the best of my knowledge. I agree to inform VNSNY CHOICE, promptly of any change in the information provided in this application. I understand that false or misleading information or the withholding of information deemed relevant by VNSNY CHOICE will disqualify this Membership Application from consideration as a VNSNY CHOICE participating provider.

In signing this application, I acknowledge that this information is provided to VNSNY CHOICE for the purpose of developing a subcontract with the applicant organization. I further understand that my completion and submission of this application only entitles the applicant organization to be considered as a participating provider. I understand that any decision with respect to my becoming a participating provider in the VNSNY CHOICE provider network remains the sole discretion of VNSNY CHOICE. VNSNY CHOICE may, by means which it may choose, determine the truth or accuracy of all statements made herein.

This attestation is granted with the understanding that VNSNY CHOICE will take responsible measures to maintain the confidentiality of this information.

Signature of Officer Date

Print Name of Officer

Title

Please direct any questions to VNSNY CHOICE Credentialing Department (212) 946-9106. Completed application with all supporting documentation should be e-mailed or mailed to:

VNSNY CHOICE Health Plans Attn: Provider Credentialing Dept.

220 E 42nd Street, 3rd FloorNew York, NY 10017

Email: CHOICECredentialing@vnsny.org

ATTACHMENTS

The following items must accompany your application:

All Providers: General and Professional Liability Insurance Certificate copy and malpractice claims history IRS W-9 form Report from most recent site visit conducted by any City, County or State contracting authority (if

applicable)

Transportation Providers: NYC Providers only: copy of NYC Taxi & Limo Commission Base License Outside NYC Providers: copy of NYS Dept. of Transportation registry/permit

Home Delivered Meals Providers: NYC Providers only: copy of current New York City Vendex rating letter Outside NYC Providers: copy of county or other governmental approval letter

Social Adult Day &/or Medical Adult Day Care Providers: Blank assessment and care plan Participant bill of rights Recent calendar of events Copy of Participant Eligibility Policy & Procedure Document Copy of Service Plan Policy & Procedure Document

Skilled Nursing Facility/Nursing Home: Copy of State Operating Certificate Statement of Deficiencies and plan of correction from Facility’s most recent State survey OR Copy

of letter from NYSDOH accepting plan of correction. Copy of any notice of sanctions imposed upon the nursing home by Medicare or Medicaid, or any

disciplinary actions taken by the New York State Department of Health within the past five years Copy of accreditation documents Current Medicaid Rate Sheet

Laboratories: Copy of CLIA Certificate List of locations in New York State

Hospitals, Ambulatory Surgery Centers, D & TCs, Clinics, Health Centers, Radiology Centers, Dialysis Centers, Home Health Agencies, Outpatient Rehabilitation Centers, Hospicesetc. Copy of State Operating Certificate Copy of accreditation documents List of locations in New York State

ver. 9-2013

**All SADC Forms and P&Ps should have a last revision date on the documents**

SADC CREDENTIALING REQUIRED DOCUMENTS

The following items must accompany your application:

All Providers: General/Professional/Automobile/Worker's Compensation Liability Insurance Certificate Copy IRS W-9 form, ADA Accessibility Attestation Liability Claims History Report

o SADC Policies and Procedures addressing:a). Participant eligibilityb). Participant service plan (care plan)c). Services delivery (services offered at the SADC)d). Records and recordkeeping (including administrative and member records and confidentiality)e). Admission and dischargef). Program self-evaluationg). Nutrition programh). Organizational structure and staff functionsi). Orientation and training

o Completed Disclosure of Ownership and Interest Control Statemento Copy of OMIG Certification Confirmation Noticeo Copy of current Certificate of Occupancyo Copy of any materials showing the content of orientation training and any other trainings that are provided to staff (training

manual, outlines, presentations, etc.)o Participant Bill of Rightso Blank participant assessment form (including medication form)o Blank participant care plan formo Blank participant attendance formo Blank transportation documentation form (if transportation is provided)o Sheet detailing emergency contact informationo Emergency preparedness program (fire, flood, choking, fainting)o Copies of current insurance certificates for automotive liability insurance (if transportation is provided)o Copy of any materials showing the content of any new trainings introduced over the past year that are provided to staff, as

applicable (training manual, outlines, presentations, etc.)o One year of training attendance sheetso Current activity attendance rostero Current calendar of eventso Current transportation log (if transportation services offered)o Copies of contracts with third party vendorso Copy of the SADC’s current menu(s)

Copy of each of the following, if applicable:

o The current license of the Nutritionist or RN who provides oversight of the SADC’s menuo Proof of current participation in the USDA Child and Adult Care Food Program (CACFP)o Proof of current participation in NYC DFTA Home Delivered Meals Program

Documents To Be Reviewed Obtained During Site Visit

o De-Identified health records of staff or attestation from supervisor on-site documenting annual assessment of staff health

records and bi-annual PPD skin tests

1

Instructions

Please answer each question and sub question by filling in the appropriate circle. Then, based on your practice location, mail the completed attestation and any related documentation:

VNSNY CHOICE Health PlansAtt: Credentialing Department

220 E 42nd Street, 3rd Floor New York, NY 10017

If you are completing this form on behalf of a practice, please attach a listing of practitioners at your office. If your practice has more than one location, please complete a form for each location and attach a

listing of practitioners for each location. Once submitted, please notify VNSNY CHOICE Credentialing Department within 10 business days of any change to your answers below.

Note: If you do not see patients at the address above (e.g., you’re an inpatient provider only or administrative only). Please answer N/A below, sign the form and mail it back.

N/A Provider Signature Date

YES NO NA 1. Does the office have at least one wheelchair-accessible path from

an entrance to an exam room?

2. Examination tables and all equipment are accessible topeople with disabilities

3. If parking is provided, spaces are reserved for people withdisabilities, pedestrian ramps at sidewalks, and drop-offs?

4. If parking is provided, are there an adequate number of parkingspaces provided (8 feet wide for a car and 5 foot access aisle)? TotalSpaces Accessible Spaces

� 1-25 1 � 26-50 2 � 51-75 3 � 76-100 4

Date: P ractice Name (print):

Practice Address (print):

2

5. For a provider with a disability-accessible parking space, is there a path of travel from the disability-accessible parking space to the

facility entrance that does not require the use of stairs?

• Is the path of travel stable, firm and slip resistant?

• Except for curb cuts, is the path at least 36 inches wide?

6. Is there a method for persons using wheelchairs or that require othermobility assistance to enter as freely as everyone else?

• Is that route of travel safe and accessible for everyone,including people with disabilities?

7. Does the main exterior entrance door used by persons withmobility disabilities to access public spaces meet the following standards:• 32 inches clear opening.• 18 inches of clear wall space on the pull side of the door, next to the

handle.• The threshold edge is no greater than ¼ inch high or if beveled, no

greater than ¾ inches high.• The door handle is no higher than 48 inches high and can be

operated with a closed fist.

YES NO NA 8. Does the office have at least one wheelchair-accessible path from

an entrance to an exam room? Are there ramps to permitwheelchair access?If yes, complete the following 4 questions:

• Are the slopes of the ramp accessible for wheelchair access?• Are the railings sturdy and high enough for wheelchair access?• Is the width between railings wide enough to

accommodate a wheelchair?• Are the ramps nonslip and free from any obstruction

(cracks)?

9. If there are stairs at the main entrance, is there also a ramp or liftor is there an alternative accessible entrance?

10. Do any inaccessible entrances have signs indicating the location of thenearest accessible entrance?

11. Can the accessible entrance be used independently and withoutassistance?

12. Are doormats ½ inch high or less with beveled or secured edge?

13. Are waiting rooms and exam rooms accessible to people withdisabilities?

3

22. With respect to the public restroom, the accessible route, the exterior doorand the interior stall doors comply with standards set forth above forexterior doors?

23. There is at least one wheelchair accessible stall in the public restroom thathas an area of at least 5 feet by 5 feet, clear of the door swing; OR there is at least one stall that is less accessible but that provides greater access than a typical stall (either 36 by 69 inches, or 48 by 69 inches)?

24. In the accessible stall of the public rest room there are grab bars behindand on the side wall nearest the toilet?

14. The layout of the interior of the building allows people withdisabilities to obtain materials and services without assistance?

15. The interior doors comply with the criteria set forth aboveregarding the exterior door?

16. The accessible routes to all public spaces in the facility are 31inches wide?

17. There is a 5 foot circle or a T-shaped space for a disabled personusing a wheelchair to reverse direction in public areas whereservices are rendered?

18. All buttons or other controls in the hallway are no higher than 42inches?

19. Elevators in the facility meet the following standards:• There are raised and Braille signs on both door jambs on every

floor. Yes No• The call buttons in the hallway are not higher than 42 inches.

Yes No• The controls inside the cab have raised and Braille

lettering. Yes No

20. Are sign language interpreters and other auxiliary aids andservices provided in appropriate circumstances?

21. Is the public lavatory wheelchair-accessible?

4

25. There is one lavatory in the public restroom that meets thefollowing standards:

o 30 inches wide by 48 inches; deep bar space in front.? (Amaximum of 19 inches of the required depth may be under thelavatory.) ?

o The lavatory rim is no higher than 34 inches?o There is at least 29 inches from the floor to the bottom of

the lavatory apron?o The faucet can be operated with a closed fist?o The soap dispenser and hand dryers are within reach and

usable with one closed fist?o The mirror is mounted with the bottom edge of the

reflecting surface 40 inches from the floor or lower?

I, [First and Last Name, Title], hereby attest that we are a provider that has a physical site at which FIDA Participants might possibly be physically present and that the answers provided are accurate. Also, I do hereby attest that I hold the authority to make these attestations.

Date: Submitter Name (print):

Submitter Signature:

 

 

Attestation of Compliance with Background Screening Requirements   I, hereby attest that background verifications was performed upon hire for all employees (typically this includes a criminal background check, sex offender registry check, or drug screen per state regulations) of ________________________.   ____________________________ maintains copies of each employee’s criminal background 

check reports in his/her personnel file. 

I declare the above statement is true and accurate to the best of my knowledge.  

 

 

_______________________________   Print Name  _______________________________   Signature  _______________________________   Date  

 

 

 

 

**This background attestation is valid for a period of three years from date of execution.  

 

 

Subject: Disclosure of Ownership and Control Interest Statement Dear Provider: By federal law, the U.S. Department of Health and Human Services’ Office of Inspector General (HHSOIG) can exclude individuals and entities from participating in federal health care programs – including Medicaid and Medicare. If the HHS-OIG excludes a health care provider under a Medicaid program, the U.S. Department of Health and Human Services’ Centers for Medicare & Medicaid Services (CMS) policy also prohibits the reimbursement of any items or services furnished, ordered or prescribed by that provider. The federal regulation set forth in 42 CFR 455.106 requires providers who are entering into or renewing a provider agreement to disclose the identity of any excluded individuals/entities with ownership or control interest in the provider of 5 percent (5%) or greater. This disclosure of information is required to the U.S. Department of Health and Human Services and managed care organizations that contract with DHHS. Please see the definitions for further explanation of an ownership interest, managing employee and direct and indirect ownership. Federal regulation 42 CFR 455.105 requires contracting providers to disclose information within 35 days of a request by CMS, DHHS or managed care organizations on: 1. The ownership of any subcontractor with whom the provider has had business transactions totaling more than $25,000 during the 12-month period ending on the date of the request; and 2. Any significant business transactions between the provider and any wholly owned supplier, or between the provider and any subcontractor, during the 5-year period ending on the date of the request. Instructions Please follow these instructions to adhere to federal regulations: 1. Review the HHS-OIG list for excluded individuals at http://www.oig.hhs.gov/fraud/exclusions.asp and determine if any individuals who meet the criteria for ownership or control interest are on the exclusion list. 2. Please return the completed form with your credentialing application.

Definitions Agent: Any person who has been delegated with the authority to obligate or act on behalf of the provider Disclosing Entity: A Medicaid provider (other than a practitioner or group of practitioners) or fiscal agent Other Disclosing Entity: Any other Medicaid disclosing entity and any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under Title V, XVIII, or XX of the Act. This includes any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic or health maintenance organization that participates in Medicare; OR, any entity (other than a practitioner or group of practitioners) that furnishes or arranges for the furnishing of health-related services for which it claims payment under any plan or program established under Title V or Title XX of the Act. Group of Practitioners: Two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff or common equipment. Indirect Ownership: Any ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes ownership interest in any entity that has an indirect ownership interest in the disclosing entity. Managing Employee: A general manager, business manager, administrator, director or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day-today operation of an institution, organization or agency. Ownership Interest: The possession of equity in the capital, the stock or the profits of the disclosing entity. Person with an Ownership or Control Interest: A person or corporation that: a) Has an ownership interest totaling 5 percent or more in a disclosing entity; b) Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; c) Has a combination of direct and indirect interests equal to 5 percent or more in a disclosing entity; d) Owns an interest of 5 percent or more in any mortgage, deed of trust, note or other obligation secured by the disclosing entity if that interest equals 5 percent of the value of the property or assets of the disclosing entity; e) Is an officer or director of a disclosing entity that is organized as a corporation; or f) Is a partner in a disclosing entity that is organized as a partnership. Significant Business Transaction: Any business transaction or series of transactions that, during any one fiscal year, exceeds the lesser of $25,000 and 5 percent of a provider’s total operational expenses.

Subcontractor: An individual, agency or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of provider medical care to its patients. Supplier: An individual, agency or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid. Wholly Owned Supplier: A supplier whose total ownership interest is held by a provider or by a person, persons or other entity with an ownership or control interest in a provider.

Disclosure of Ownership and Control Interest Statement

The federal regulations set forth in 42 CFR 455.104, 455.105 and 455.106 require providers who are entering into or renewing a provider agreement to disclose to the U.S. Department of Health and Human Services, the State Medicaid Agency, and to managed care organizations that contract with the State Medicaid Agency: 1) the identity of all owners with a control interest of 5% percent or greater, 2) certain business transactions as described in 42 CFR 455.105 and 3) the identity of any excluded individual or entity with an ownership or control interest in the provider, the provider group, or disclosing entity or who is an agent or managing employee of the provider group or entity. Please attach a separate sheet if necessary. Practice Information Check one that most closely describes you: Individual Group Practice Disclosing Entity Name of Individual, Group Practice or Disclosing Entity: DBA Name: Address: Federal Tax Identification Number:

Section I List the name, title, address, date of birth (DOB) and Social Security Number (SSN) for each individual having an ownership or control interest of 5 percent or greater in this provider entity. List the name, Tax Identification Number (TIN) and business address of each organization, corporation or entity having an ownership or control interest of 5 percent or greater. Please attach a separate sheet if necessary. (42 CFR 455.104)

Name of individual or entity DOB Address

SSN (if listing an individual)

TIN (if listing an entity)

Section II Are any of the individuals listed above related to each other? Yes No If yes, list the individuals named above who are related to each other (spouse, sibling, parent, child). (42 CFR 455.104)

Names Relationship

Section III Are there any subcontractors that the Disclosing Entity has direct or indirect ownership of 5% percent or more? Yes No If yes, list the name and address of each person with an ownership or controlling interest in any subcontractor used in which the disclosing entity has direct or indirect ownership of 5% percent or more. (42 CFR 455.104)

Name of individual or entity DOB Address

SSN (if listing an individual)

TIN (if listing an entity)

Section IV Has any person who has an ownership or control interest in the provider, or is an agent or managing employee of the provider ever been convicted of a crime related to that person’s involvement in any program under Medicaid, Medicare or Title XX program? Yes No (verify through HHS-OIG Web site) If yes, please list those persons below. (42 CFR 455.106)

Name/Title DOB Address

SSN

Section V Business Transactions: Has the disclosing entity had any financial transaction with any subcontractors totaling more than $25,000 or any significant business transactions with any subcontractors? Yes No If yes, list the ownership of any subcontractor with whom this provider has had business transactions totaling more than $25,000 during the previous twelve 12-month period; and any significant business transactions between this provider and any wholly owned supplier, or between the provider and any subcontractor, during the past five-year period. (42 CFR 455.105). Attach a separate sheet if necessary.

Name/Supplier/Subcontractor Address

Transaction Amount

Section VI Have you identified your status (under Practice Information1) as a Disclosing Entity? Yes No If yes, for Disclosing Entities, list each member of the Board of Directors or Governing Board, including the name, date of birth (DOB), Address, Social Security Number (SSN) and percent of interest.

Name/Title DOB Address

SSN % Interest

I certify that the information provided herein is true and accurate. Additions or revisions to the information above will be submitted immediately upon revision. Additionally, I understand that misleading, inaccurate or incomplete data may result in a denial of participation. ______________________________________________ ____________________________________ Signature Title (or indicate if authorized Agent

______________________________________________ ____________________________________ Name (please print) Date 

ATTESTATION OF HEALTH ASSESSMENT

I, ______________________ [insert name], the _______________ [insert title] at

______________________ [insert name of Facility/Institution] hereby attest that all staff

who have contact with participants at our center:

_____ have had their health status assessed and documented prior to contact with any participant to ensure that they are free from any health impairment that is of potential risk to others or may interfere with the performance of their duties; _____ have had their health status assessed and documented annually thereafter to ensure that they are free from any health impairment that is of potential risk to others or may interfere with the performance of their duties. _____ have had a PPD (Mantoux) skin test for tuberculosis prior to employment and no less than every two years thereafter for a negative finding. I hereby further attest that the above is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact could lead to termination of my contract with VNSNY CHOICE.

_____________________________ Signature

_____________________________

Print Name

_____________________________ Date

As of May 2016

ANNUAL ATTESTATION FOR FIRST TIER, DOWNSTREAM AND RELATED ENTITIES LICENSED HOME CARE SERVICES AGENCIES

______________________ (“LHCSA”) is contracted with VNSNY CHOICE Health Plans (“VNSNY CHOICE”) to furnish licensed home care agency services to VNSNY CHOICE’s members. I have the authority to attest on behalf of LHCSA, and I hereby attest that LHCSA is in compliance with all federal and state requirements applicable to First Tier, Downstream and Related Entities (“FDRs”) and LHCSAs as set forth in this attestation.

To complete this attestation, please initial where indicated in each section, check all applicable boxes, attach all supporting documents, and sign on the last page.

GENERAL ATTESTATIONS

STANDARDS OF CONDUCT: LHCSA has received and reviewed VNSNY CHOICE’s standards of conduct, including the VNSNY CHOICE Compliance Plan and Code of Conduct, and applicable policies and procedures, at the time of contracting, annually, and when standards are updated, and distributes these standards to all officers, directors, managers, employees and contractors (collectively, “personnel”) at time of hire, annually, and when standards are updated; or

LHCSA maintains its own Code of Conduct and policies and procedures particular to LHCSA, and distributes these materials to all personnel at time of hire, annually, and when standards are updated. A copy of LHCSA’s Code of Conduct is provided with this attestation.

LHCSA obtains a written certification, within 90 days of hire and annually thereafter, that all personnel have received, read, and will comply with all written standards of conduct described in this section.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

CONFLICTS OF INTEREST: LHCSA has a Conflict of Interest Policy. A copy of the LHCSA’s Conflict of Interest Policy is provided with this attestation.

LHCSA obtains a written certification from all personnel at the time of hire and annually thereafter, which states, at a minimum: o That the individual has reviewed the LHCSA’s Conflict of Interest Policy;o That the individual has disclosed any potential conflicts of interest; ando That the individual has obtained the appropriate approval to work despite any conflicts or has

eliminated the conflict.LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

NON-RETALIATION POLICY: LHCSA has a policy that prohibits retaliation against anyone who in good faith reports potential non-compliance, fraud, was waste and abuse (“FWA”), or violations of its Code of Conduct, and this policy is publicized throughout the LHCSA.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

PRIVACY AND SECURITY STANDARDS: LHCSA shall promptly notify VNSNY CHOICE in writing of any and all suspected and actual security or privacy breaches involving any protected health information, personally identifiable information, or financial information (collectively, “Protected Information”) of a VNSNY CHOICE member, employee or other individual whose Protected Information LHCSA has access to as a result of its relationship with VNSNY CHOICE.

-2- As of May 2016

LHCSA adheres to all security and privacy standards and requirements referenced in its contract with VNSNY CHOICE, including HIPAA.

In the event that LHCSA enters into a contract with an entity that performs functions on behalf of LHCSA that involve any Protected Information, it will incorporate into the contract the appropriate provisions required by VNSNY CHOICE to protect the Protected Information.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

GENERAL AND SPECIFIC COMPLIANCE TRAINING: LHCSA ensures the administration of general compliance training and, if necessary, specialized or department specific compliance training, to personnel responsible for the administration or delivery of benefits, upon the initial adoption of a compliance program, within 90 days of hire, and annually thereafter.

LHCSA maintains records of the time, attendance, topics, and results of trainings within the LHCSA. LHCSA obtains a written certification from all personnel, upon completion of training and no less than annually thereafter, that they have received general compliance training and, as applicable, specialized or department specific training.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

FRAUD, WASTE, AND ABUSE COMPLIANCE TRAINING: Please select the method of training and education that LHCSA uses to comply with this requirement

(please select at least one option in support of the attestation): LHCSA personnel have completed the Medicare Advantage and Part D Sponsor FWA training via the Centers for Medicare & Medicaid Services (“CMS”) Medicare Learning Network. Date training was completed by all relevant personnel _______________ (month/day/year)

LHCSA personnel have completed Medicare FWA compliance training provided by another Medicare Advantage and Part D sponsor or another source. The name of the source is ______________________. Date training was completed by all relevant personnel _______________ (month/day/year)

LHCSA personnel have completed LHCSA’s own Medicare FWA compliance training, a copy of which is included. Date training was completed by all relevant personnel_______________ (month/day/year)

LHCSA is enrolled in Medicare Parts A or B and is therefore deemed to have satisfied the annual Medicare FWA education and training requirement

LHCSA will furnish training materials, including, but not limited to, training logs and training program materials from third party training or training conducted by LHCSA, to VNSNY CHOICE upon request to validate that training was completed. LHCSA will also obtain attestations from any other entities with which it has contracted to provide health, prescription, and/or administrative services to VNSNY CHOICE and, upon request, will obtain training logs and attestations to verify that Medicare FWA Training was completed by those downstream entities.

Medicare FWA compliance training has been provided to all personnel responsible for the administration or delivery of Medicare Advantage and Part D benefits upon the initial adoption of a compliance program, within 90 days of hire, and annually thereafter.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

GENERAL MEDICARE COMPLIANCE TRAINING: Please select the method of training and education that LHCSA uses to comply with this requirement

(please select at least one option in support of the attestation): LHCSA personnel have completed the Medicare Advantage and Part D General Compliance Training module via the CMS Medicare Learning Network. Date training was completed by all relevant personnel _______________ (month/day/year)

LHCSA personnel have completed Medicare compliance training course provided by another Medicare Advantage and Part D sponsor or another source. The name of the source is ______________________. Date training was completed by all relevant personnel _______________ (month/day/year)

LHCSA personnel have completed LHCSA’s own Medicare compliance education and training, a copy of which is included. Date training was completed by all relevant personnel _______________ (month/day/year)

LHCSA will furnish training materials, including, but not limited to, training logs and training program materials from third party training or training conducted by LHCSA, to VNSNY CHOICE upon request to

-3- As of May 2016

validate that training was completed. LHCSA will also obtain attestations from any other entities with which it has contracted to provide health, prescription, and/or administrative services to VNSNY CHOICE and, upon request, will obtain training logs and attestations to verify that Medicare compliance training was completed by those downstream entities.

Medicare compliance training has been provided to all personnel responsible for the administration or delivery of Medicare Advantage and Part D benefits upon the initial adoption of a compliance program, within 90 days of hire, and annually thereafter.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

GENERAL MEDICAID COMPLIANCE TRAINING: Please check all trainings that are provided to LHCSA personnel or if such trainings are not applicable to

LHCSA. All relevant personnel have received Medicaid/OMIG compliance training.

Date training was completed by all relevant personnel _______________ (month/day/year); or Not applicable

All relevant personnel have received compliance training to oral health providers in its network on the HIV and Oral Health Guidelines promulgated by the New York State Department of Health.

Date training was completed by all relevant personnel _______________ (month/day/year); or Not applicable

All relevant personnel have received HIV Education and Training. Date training was completed by all relevant personnel _______________ (month/day/year); or

Not applicable All relevant personnel have received HIV Confidentiality Training.

Date training was completed by all relevant personnel _______________ (month/day/year); or Not applicable

LHCSA will furnish training materials, including, but not limited to, training logs and training program materials from third party training or training conducted by LHCSA, to VNSNY CHOICE upon request to validate that training was completed. LHCSA will also obtain attestations from any other entities with which it has contracted to provide health, prescription, and/or administrative services to VNSNY CHOICE and, upon request, will obtain training logs and attestations to verify that Medicaid compliance training was completed by those other entities.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section, or that certain training requirements are not applicable to LHCSA: ____ (Initials)

FULLY INTEGRATED DUALS ADVANTAGE (“FIDA”) TRAINING: (Applies only to FIDA providers) LHCSA is a FIDA participating provider, and all relevant personnel have completed the FIDA training via https://fida.resourcesforintegratedcare.com. Date training was completed by all relevant personnel _______________ (month/day/year); or

LHCSA is not contracted with VNSNY CHOICE as a FIDA participating provider, and therefore its personnel are not required to complete the FIDA training.

LHCSA attests that it is in compliance with the requirement set forth in this section, or that this requirement is not applicable to LHSCA because it is not a FIDA participating provider: ____ (Initials)

EXCLUSION LISTS: LHCSA reviews the required exclusion/sanction lists, including, without limitation, the OIG, OMIG, and SAM (formerly GSA), exclusion lists upon initial hire/engagement of personnel and then every 30 days thereafter to ensure that any individual responsible for administering or delivering benefits is not excluded from federal health care programs.

In the event that any individual responsible for the administration or delivery of any VNSNY CHOICE service or benefit is found to be on the exclusion lists, LHCSA immediately removes that individual from any work related directly or indirectly to all federal health care programs, ensures that appropriate corrective actions have been taken, and promptly reports the matter to VNSNY CHOICE.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

-4- As of May 2016

MAINTENANCE OF RECORDS: LHCSA maintains books, records, documents, and other evidence of accounting procedures and practices adhering to specified requirements related to the administration of VNSNY CHOICE services and/or benefits for a minimum of 10 years.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

OFFSHORE CONTRACTOR1 ARRANGEMENTS: LHCSA will inform VNSNY CHOICE of any offshore contractor or subcontractor arrangements within 15 calendar days of signing an offshore contract.

LHCSA will submit the required contractor/subcontractor information as well as offshore contractor attestations via the HPMS module.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

ATTESTATION OF DISCIPLINARY AND TERMINATION ACTIONS: LHCSA will provide to VNSNY CHOICE, at least quarterly, a signed attestation listing all identified personnel, vendors or downstream entities that had a disciplinary or termination action related directly to Medicare non-compliance or FWA. The attestation will detail, at minimum: o Specific steps taken in response to violation;o Information uncovered during LHCSA’s investigation process;o Report of findings/investigation;o Written disciplinary actions issued; ando Record of violation and consequences (including disciplinary actions) being reported to the LHCSA’s

board, senior management, or others within the organization.LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

NOTIFICATION OF NON-COMPLIANCE OR FWA: In accordance with CMS requirements, LHCSA will immediately report all suspected or known instances of Medicare and/or Medicaid noncompliance and/or FWA issues to VNSNY CHOICE within three business days by contacting the Compliance Department directly or via the Compliance Hotlines.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

LHCSA-SPECIFIC ATTESTATIONS

COMPLIANCE WITH LHCSA REQUIREMENTS: LHCSA has written policies and procedures that address compliance with 10 N.Y.C.R.R. Part 766 (LHCSA Minimum Standards).

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.1 regarding patient rights, including maintaining written policies and procedures regarding patient rights and informing patients of their rights.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.2 regarding patient services, including maintaining written policies and procedures for each service and ensuring that delivery of each service is documented in the clinical record.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.3 regarding plan of care, including maintaining a plan of care for each patient that contains all required elements and is reviewed at least every six months.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.4 regarding medical orders, including ensuring that an order from the patient’s authorized practitioner is established and documented for the health care services provided by the LHCSA and that the order is reviewed at least every six months.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.5 regarding clinical supervision, including ensuring that all staff delivering care are adequately supervised by appropriately trained and oriented supervisory staff (e.g., registered professional nurses, licensed practical nurses) and in-home supervision occurs.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.6 regarding patient care records, including maintaining a confidential record for each patient and maintaining policies and procedures regarding the safeguarding of clinical records.

1 The United States Government Accountability Office defines offshore contracting or subcontracting as an arrangement whereby a FDR provides services that are performed by workers located in one or more foreign countries, regardless of whether the workers are employees of U.S. or foreign companies.

-5- As of May 2016

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.9 regarding the responsibilities of the LHCSA’s governing authority or operator.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.10 regarding contracts for patient care services, including ensuring that any contracts include the terms specified in the regulations and ensuring that the LHCSA will maintain ultimate responsibility for compliance with applicable law and the quality of services provided.

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.11 regarding personnel, including: ensuring that applicable personnel meet the qualifications for home health aides and personal care aides; maintaining a record of required health tests and other documentation regarding applicable personnel; verifying the personal identity, employment history and qualifications of personnel; and conducting an assessment of performance at least annually through an in-home visit (if applicable).

LHCSA is in compliance with 10 N.Y.C.R.R. § 766.12 regarding records and reports, including retaining records on site at the LHCSA and promptly submitting records or reports required by the New York State Department of Health.

LHCSA attests that it is, and will remain, in compliance with all requirements set forth in this section: ____ (Initials)

*********************************************************************************************

In accordance with Section XVI of the Agreement between LHCSA and VNSNY CHOICE, I understand that VNSNY CHOICE reserves the right to audit the accuracy of the information provided in this attestation and to monitor LHCSA’s compliance with applicable law. I further understand that LHCSA may be subject corrective action, including, but not limited to, termination, in the event that LHCSA is found to be non-compliant with any federal and state requirements applicable to FDRs and LHCSAs, as set forth in this attestation.

By my signature below, I certify that all information provided in this attestation is true and correct to the best of my knowledge, information and belief, after having made a reasonable inquiry.

______________________________ _____________________________ Signature of LHCSA Representative Title of Signing Representative

________________________________ _____________________________ Printed Name of Signing Representative Date

-6- As of May 2016

ATTACHMENTS

Please use the below document checklist and indicate the documents that you will be providing VNSNY CHOICE to complete the Attestation:

1 LHCSA’s own Code of Conduct

2. LHCSA’s own Conflict of Interest Policy

3. General Medicare Compliance Program training materials

4. General Medicare Compliance Program training materials (LHCSA’s own Medicare compliance educationand training)

5. Fraud, waste and abuse training materials via CMS Medicare Learning Network or other third party

6. Fraud, waste and abuse training materials from LHCSA’s own internal training

7. LHCSA’s Non-Retaliation Policy

8. Training logs, sign-in sheets and training program materials from third-party training to validate that theabove trainings were completed

9. Training conducted by the LHCSA to validate that the above trainings were completed

10. A list of any other entities with which LHCSA have contracted to provide health, prescription, and/oradministrative services on behalf of VNSNY CHOICE

11. If LHCSA is enrolled in Medicaid, a copy of the most recent Certification of the Compliance Program tothe OMIG

Form W-9(Rev. December 2014)Department of the Treasury Internal Revenue Service

Request for Taxpayer Identification Number and Certification

Give Form to the requester. Do not send to the IRS.

Pri

nt o

r ty

pe

See

Sp

ecifi

c In

stru

ctio

ns o

n p

age

2.

1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2 Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification; check only one of the following seven boxes:

Individual/sole proprietor or single-member LLC

C Corporation S Corporation Partnership Trust/estate

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=partnership) ▶

Note. For a single-member LLC that is disregarded, do not check LLC; check the appropriate box in the line above for the tax classification of the single-member owner.

Other (see instructions) ▶

4 Exemptions (codes apply only to certain entities, not individuals; see instructions on page 3):Exempt payee code (if any)

Exemption from FATCA reporting

code (if any)(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.)

6 City, state, and ZIP code

Requester’s name and address (optional)

7 List account number(s) here (optional)

Part I Taxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid backup withholding. For individuals, this is generally your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.

Note. If the account is in more than one name, see the instructions for line 1 and the chart on page 4 for guidelines on whose number to enter.

Social security number

– –

orEmployer identification number

–

Part II CertificationUnder penalties of perjury, I certify that:

1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3. I am a U.S. citizen or other U.S. person (defined below); and

4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions on page 3.

Sign Here

Signature of U.S. person ▶ Date ▶

General InstructionsSection references are to the Internal Revenue Code unless otherwise noted.

Future developments. Information about developments affecting Form W-9 (such as legislation enacted after we release it) is at www.irs.gov/fw9.

Purpose of FormAn individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns include, but are not limited to, the following:

• Form 1099-INT (interest earned or paid)

• Form 1099-DIV (dividends, including those from stocks or mutual funds)

• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)

• Form 1099-B (stock or mutual fund sales and certain other transactions by brokers)

• Form 1099-S (proceeds from real estate transactions)

• Form 1099-K (merchant card and third party network transactions)

• Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition)

• Form 1099-C (canceled debt)

• Form 1099-A (acquisition or abandonment of secured property)

Use Form W-9 only if you are a U.S. person (including a resident alien), to provide your correct TIN.

If you do not return Form W-9 to the requester with a TIN, you might be subject to backup withholding. See What is backup withholding? on page 2.

By signing the filled-out form, you:

1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2. Certify that you are not subject to backup withholding, or

3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4. Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting? on page 2 for further information.

Cat. No. 10231X Form W-9 (Rev. 12-2014)