Home / Forms / Appendix O

Billing Compliance Attestation

Certification of accurate and compliant billing practices.

Kura Solution

Appendix O — Billing Compliance Attestation

Certification of accurate and compliant billing practices.

I certify that:

Services billed are medically necessary, authorized, and provided
Documentation supports all claims
No duplicate or fraudulent billing occurs
Recovery Works and Medicaid regulations are followed

Staff Name / Title *

Signatures

Staff Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Staff Printed Name *

Date *

Supervisor Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Supervisor Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.