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Annual Provider Data Management Audit Attestation

Home » Annual Provider Data Management Audit Attestation

Annual Provider Data Management Audit Attestation

If NO changes are needed or if the provider has terminated from the practice, please complete the online provider data management audit attestation form. All field marked with a RED asterisk (*) are required in order to proceed.

Audit Form Verification

Provider Audit ID(Required)

Date of Audit Request(Required)

MM slash DD slash YYYY

Tax ID Number(Required)

Numeric Only

Group Information Survey

Please complete this section specific to the Audit's Tax ID Number

Services Performed(Required)

Primary Care

Behavioral Health

OB / GYN

Other

Please select all that apply

Other Service Performed(Required)

Other Services Performed

Contracted ProviDRs Care Products

Please Select All that Apply

ProviDRs Care Network

NexUS Tier 1 Primary Care Physician Group

Clinical Staff Languagaes(Required)

Please list all languages spoken by Clinical Staff only

English

Other Languages Spoken

Additional Language Spoken(Required)

Additional Language Spoken

Audit Form Attestation

Provider Data Management Audit Form Attestation(Required)

I have reviewed the Annual Provider Data Management Audit Form and attest all the information on the audit form is correct and NO changes need to be made.

Provider is no longer associated with our practice

Other Reason for Termination(Required)

Provider Termination Date

MM slash DD slash YYYY

Termination Details

left current group to start / join a new group

relocated to another state

Retired

Deceased

Other

Submitter's Contact Information

If any additional information is needed we will follow up with the contact listed below.

Name(Required)

First Last

Position(Required)

Phone(Required)

Email(Required)