The Company hereby:
1. Acknowledges receipt of Southwell Ambulatory, Inc. Compliance Program and agrees to read the Program, Code of Conduct and any specific compliance policies and procedures forwarded to the Company;
2. Certifies and represents that the officers or directors of the Company have not been convicted of any crime related to healthcare;
3. Certifies and represents that the Company is not debarred, excluded or otherwise ineligible to participate in any state or federal healthcare program for the provision of items or services for which payment may be made by a state or federal healthcare program;
4. Certifies that the Company has not contracted with any employee, contractor, agent, or vendor knowing that the contracting party is excluded from participation in any state or federal healthcare program;
5. Acknowledges awareness of Southwell Ambulatory, Inc. Helpline and the availability of this Helpline to employees of the Company to report matters to Southwell Ambulatory, Inc. related the work done for Southwell Ambulatory, Inc. facilities;
6. Certifies and represents that the Company shall participate and adhere to Southwell Ambulatory, Inc. Compliance Program in connection with performing services for Southwell Ambulatory, Inc., including immediately investigating any report or indication of errors or wrongdoing that results in overpayment of funds to Southwell Ambulatory, Inc. or may create liability to Southwell Ambulatory, Inc. or to the Company for work done by or for Southwell Ambulatory, Inc. and shall report such findings to Southwell Ambulatory, Inc.; and
7. Agrees to make all employees directly involved in providing services or products to Southwell Ambulatory, Inc. aware of the above certifications and acknowledgments.
Southwell Ambulatory, Inc.’s Compliance Program requires that all vendors make annual certifications. Please complete the information and submit as directed.
By typing his/her individual name below, the Company representative represents and warrants that he/she is an authorized representative of the Company and that the Company thereby executes the Southwell Ambulatory, Inc.’s Company Vendor Compliance Attestation form as of the date of submission. The submission must contain the representative's name and title.