Healthcare Exclusion Attestation Form
Use this form to attest to healthcare exclusion status and provide the supporting details needed for review. No emojis. No claim of HIPAA compliance.
Attestation Details
Full Name
*
First Name
Last Name
Professional Role or Relationship
*
Organization / Company Name
*
Email Address
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Exclusion Attestation
Exclusion status
*
Excluded
Not excluded
Unsure
Attestation date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Exclusion details or explanation
Declaration and Submission
Acknowledgment
*
I confirm that the information provided is accurate and submitted in good faith
Attester Signature
*
Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Submit
Submit
Should be Empty: