FDR Compliance Attestation

The Compliance Attestation form is used to confirm that the FDR or Affiliate is in compliance with VA Premier FDR and Affiliate Compliance Policy for the Commonwealth Coordinated Care program.

Step 1 of 3

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  • First Tier, Downstream, or Related Entity (FDR) and Affiliate Compliance Attestation

    The Compliance Attestation is used to confirm that the FDR or Affiliate is in compliance with VA Premier FDR and Affiliate Compliance Policy for the Commonwealth Coordinated Care program.

    All First Tier, Downstream or Related Entity and Affiliates that are contracted to provide administrative and healthcare services to Medicare and Medicaid enrollees by VA Premier CompleteCare must complete a Compliance Attestation. The Attestation must be signed by an authorized representative when the FDR or Affiliate first contract with VA Premier CompleteCare and annually thereafter.

    An authorized representative is a Compliance Officer, Chief Medical Officer, Practice Manager, Executive Officer, Provider, Owner, or equivalent authoritative representative.

    Only one Compliance Attestation form is required for each FDR and Affiliate.

  • Please list any subcontracted or affiliated vendors you currently utilize for any contracted duties assigned to your organization for Virginia Premier's CompleteCare Program.