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Attestation Forms

NOTE: Please ensure your cover letter clearly shows the original attestation form is being submitted to WPS and an exact duplicate courtesy copy is being forwarded to the appropriate CMS Regional Office (RO). It is suggested that the provider addresses the letter to WPS and includes appropriate CMS RO as the cc: at the bottom of the letter. This way both WPS and CMS get the same letter that clearly indicates both organizations were copied appropriately.

CMS Sample Attest Form

WPS's Sample Attest Form

Note: This is WPS's sample of the attestation form. It is a replica of CMS sample attestation form, with added notes of when additional documentation is necessary to review the providers attestation without minimal follow-up for needed support/documentation. This is not a required format to use, just another sample to consider in using.

Attestation Cover Sample

Note: CMS recommends that providers place the initial page of the attestation on the official letterhead of the main provider if you elect to use this form or any other format.

This Word document is only an example of WPS's initial page relating to their sample version of the attestation form. If you paste this onto your letterhead and all of this information fits onto one page, then you will be able to replace the pdf version page 2 with this, and place page 3 of WPS's attestation form following this page.

Provider Based Designation Checklist

CMS provider-based checklist to assist with provider's submitting the required documentation.

Provider Based Index

An index of all the documentation required to be approved for provider-based. The first two pages contain a list of all documentation potentially required to be approved for provider based by CMS RO. The remaining pages contain lead sheets for all the individual exhibits.