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.

Contact Palmetto GBA JM Part A Medicare

Provider Contact Center: 855-696-0705

Email Part A

Contact a specific JM Part A department

Other Palmetto GBA Sites

Palmetto GBA Home

DMEPOS Competitive Bidding Program

Jurisdiction J Part A MAC

Jurisdiction J Part B MAC

Jurisdiction M Part A MAC

Jurisdiction M Part B MAC

Jurisdiction M Home Health and Hospice MAC


National Supplier Clearinghouse MAC


RRB Specialty MAC Providers

RRB Specialty MAC Beneficiaries



Click to Chat Now