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Rate Certification Form Outpatient - Delaware Department Of Services For Children, Youth And Their Families Page 3

State of Delaware

Division of Management Support Services

The Department of Services

Cost Recovery Unit

For Children, Youth and

Their Families

CMS SANCTIONS CERTIFICATION FORM

Per the “SOCIAL SECURITY ACT, SEC. 1128, 42 USC Sec. 1320A-7 “Exclusion of Certain Individuals and Entities from

Participation in Medicare and State Health Care Programs,” the Secretary of U.S. Department of Health and Human

Services may exclude individuals and entities from participation in any Federal health care program, including

Medicaid and Medicare, or any State health care program.

As an authorized representative of this agency, I certify that the following is true regarding sanctions by the Centers for

Medicare & Medicaid Services (CMS), formerly HCFA.

This agency or individuals working for it have never been sanctioned by CMS.

This agency or individuals working for it were sanctioned by CMS. The agency or individuals were sanctioned on

(date)

. Please select one option below.

The sanctions have not been removed.

The sanctions were removed on (date)

. Please provide supporting documentation.

Signature of Authorized representative

Printed Name

Date

Title

Phone Number

Email Address

Agency Name

Agency Address

Agency City, State, Zip

You may attach supporting documentation if necessary.

Outpatient

Revised 12/2013

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Rate Certification Form Outpatient - Delaware Department Of Services For Children, Youth And Their Families Page 3