Form Cms-10175 - Electronic File Interchange Organization (Efio) Certification Statement

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DEPARTMENT OF HEALTH AND HUMAN SERVICES
Form Approved
CENTERS FOR MEDICARE & MEDICAID SERVICES
OMB No. 0938-0984
ELECTRONIC FILE INTERCHANGE ORGANIZATION (EFIO)
CERTIFICATION STATEMENT
By his/her signature(s) below, the authorized official(s) of___________________________________________
(hereinafter referred to as the electronic file interchange organization, or EFIO) legally binds the EFIO to full
adherence to all of the following conditions:
1. I certify that the EFIO has the written legal authority to act on behalf of any and all providers for whom the
EFIO submits information to CMS or its agent (hereinafter collectively referred to as the Enumerator). This
legal authority includes the submission of the provider’s application for a National Provider Identifier (NPI)
and, if agreed to between the EFIO and the provider, updates and changes to the provider’s NPI data,
deactivations, and other information.
2. I certify that any and all data the EFIO submits to the Enumerator on behalf of a provider will be no more
than 12 months old from the date the provider certifies to the accuracy of the data to be submitted on
his/her/its behalf.
3. For those providers on whose behalf the EFIO submits an initial application for an NPI, I certify that the
EFIO will promptly notify via letter or e-mail each provider of the latter’s newly issued NPI or, if applicable,
the rejection of the latter’s application. I further certify that the EFIO will only disseminate a provider’s NPI
for purposes permitted under Federal or State law.
4. In situations involving providers on whose behalf the EFIO submits a request to change the provider’s existing
NPI information or to deactivate the provider’s NPI, the EFIO agrees to promptly inform the provider of the
confirmation of the change.
5. I certify that each provider on whose behalf the EFIO submits a NPI application has informed the EFIO in
writing that the provider’s information that will be submitted to NPPES is accurate and complete. This
applies to the provider’s initial application for a NPI and, if agreed to between the EFIO and the provider,
updates and changes to the provider’s NPI data, and deactivations.
6. I certify that the EFIO is duly licensed to conduct business in all States that require the EFIO to obtain such
licensure prior to conducting business in that jurisdiction.
7. I certify that the EFIO will maintain records of all correspondence and communications between itself and
all providers on whose behalf the EFIO acts in the submission of NPI data to the Enumerator, and will maintain
all electronic files and records submitted to and received from the Enumerator in the course of acting on a
provider’s behalf. I certify that the EFIO will maintain such records and files referred to in this paragraph for
a period of 7 years, unless CMS prescribes a shorter period.
I further certify that the EFIO will ensure that such records and files (including, but not limited to, the NPIs
themselves) cannot be accessed by any person or entity not authorized under Federal or State law to review them.
8. I certify that the EFIO will fully and promptly cooperate with the Enumerator upon the latter’s request in all
matters relating to the verification of any information submitted by the EFIO on behalf of any provider. This
includes promptly contacting the provider at the Enumerator’s request to obtain clarification of the
provider’s data.
9. I understand that the Enumerator, on an as-needed basis, reserves the right to require the EFIO to furnish to
the Enumerator additional or clarifying information, such as written documentation, to confirm: (1) my
authority or any EFIO representative’s authority to act on behalf of the EFIO, (2) the status of any agency
relationship between the EFIO and a provider, and (3) the EFIO’s status as a legitimate business organization.
I certify that the EFIO will furnish the Enumerator with the requested information in a prompt fashion.
Form CMS-10175 (08/06) EF 09/2006
Page 1

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