Department of Human Services

MMP 3/99Medicare, Medicaid Patient and
Program Protection Act Affidavit
I HEREBY CERTIFY THAT
I am the ________________________________________________ and the duly
(Title)
authorized representative of the firm of ______________________________________________________
whose address is ________________________________________________________________________
____________________________________________________________,and that I possess the legal
authority to make this affidavit on behalf of myself and the firm for which I am acting.
In reference to the Medicare and Medicaid Patient and Program Protection Act of 1987, Public Law
100-93, at 42USC s1397(d)(a)(9), neither I, nor to the best of my knowledge, the above firm, nor any of its
officers, directors, or partners, have been convicted of or have pleaded nolo contendere to Medicare fraud, or
Medicaid fraud, or patient abuse, or have been excluded by the Secretary of Health and Human Services from
participation in the Medicare Program or excluded from any state health program.
I do solemnly declare and affirm under the penalties of perjury that the contents of this affidavit are true
and correct.
_____________________________________ ______________________________________
Witness Signa ture
__________________________________ ______________________________________
Date Printed or Typed Name