Participating Provider First Tier, Downstream, and Related Entity (FDR) Annual Attestation Form

The Centers for Medicare and Medicaid Services (CMS) require First Tier, Downstream, and Related Entities (FDRs) attest annually to specific compliance and fraud, waste, and abuse (FWA). Once you meet the program requirements, an authorized representative of your organization can complete and submit this attestation. The attestation is due no later than within the first 90 days of each calendar year or your contract participation effective date.

Definitions:

  • Attestor - The Attestor is the individual completing the form. The Attestor may be completing on their own behalf or on behalf of another individual.
  • Attested - If the Attestor is completing the form on someone else’s behalf, the Attested is the person for whom the Attestor is completing the form.

Your attestation will confirm that your organization has completed the following:

  • General compliance and fraud, waste, and abuse (FWA) training

Your attestation will confirm that your organization has or uses the following:

For Attestor completion:

*Indicates required field.

If Attestor is completing the form on someone else's behalf:

Provider FWA and Compliance Training Attestation

*By entering my information below, I am attesting that I am an entity representative who has signature authority. Each provider and staff member related to this organization has completed the FWA and General Compliance Training requirements as stated in 42 CFR. §§ 422.503(b)(4)(vi)(C) and 423.504(b)(4)(vi)(C). My group or organization has reviewed the Medicare FWA Training and General Compliance Training.