Provider-Based Attestation Statement

In order for a facility to be designated as provider-based for billing and payment purposes, it must meet the applicable requirements set forth by Centers for Medicare & Medicaid Services (CMS) in Title 42 of the Code of Federal Regulations (CFR) §413.65. Providers who believe their facility meets the criteria as a provider-based facility should submit the attestation statement to Palmetto GBA. In this statement, providers must attest that the facility meets the relevant provider-based requirements of 42 CFR §413.65. To print or download the attestation statement, please select the PDF file below.