Attestation Form (Psych Under 21 Rule ) printable pdf download

ATTESTATION

Psych Under 21 Rule

Use of restraint and seclusion in psychiatric residential treatment facilities

providing psychiatric services to individuals under age 21

Facility ______________________________________________________________________________

Mailing Address________________________________________________________________________

Physical Address of Facility if different than above_____________________________________________

City ________________________________________ State _________ Zip Code __________________

Telephone # _________________________________ Fax # __________________________________

Electronic Mail Address _________________________________________________________________

Medical Assistance Provider #____________________________________________________________

National Provider Identification (NPI) # _____________________________________________________

Total Number of Facility Beds ____________________________________________________________

Number of Medicaid residents in Facility ____________________________________________________

Number of residents for whom the Psych Under 21 benefit is paid for by another state________________

Please list all states from whom your facility has ever received Medicaid payment for the provision of the

Psych Under 21 benefit. _________________________________________________________________

____________________________________________________________________________________

Attestations: (Must be signed by an individual who has the legal authority to obligate the facility.)

______________________________________ being first duly sworn on oath states and alleges as follows:

Name / Title

A reasonable review has been conducted in the facility. Based on my best knowledge, information, belief, and

reasonable interpretation and understanding of the requirements set forth in the interim final rule governing the use of

restraint and seclusion in psychiatric residential treatment facilities providing inpatient psychiatric services to

individuals under age 21, (published on January 22, 2001, and amended with the publication of May 22, 2001) on

behalf of the facility, I hereby attest that the facility complies with all of the requirements set out in that regulation as

codified at 42 CFR §§483 Subpart G.

I understand the Centers for Medicare and Medicaid Services, the State of South Dakota Survey Agency or their

representatives may survey the facility at any time to determine compliance with the requirements, investigate

complaints lodged against the facility or to investigate serious occurrences as set forth in the Condition of Participation

as established by the interim final rule in accordance with and to the extent authorized by 42 CFR §431.610.

In addition, I agree to submit a new attestation of compliance annually and I will notify the State of South Dakota

Medicaid Agency immediately if I vacate this position so that an attestation can be submitted by my successor.

Dated this ____________ day of __________________________________, at ______________________________

Signature & Title of Owner/Administrator ____________________________________________________________

Subscribed and sworn to before me this ____________________ day of ___________________________________

My Commission expires _______________________

________________________________________________

Notary Public

Attestation Form (Psych Under 21 Rule )