I have never knowingly or willfully made any false statement or representation of a material fact in any application for any benefit or payment under a Federal or State health care program as defined in Title 42 of the United States Code, hereinafter referred to as the "Program".
I have never knowingly or willfully solicited or received any remuneration (including any kickback, bribe, or rebate) directly or indirectly, overtly or covertly, in cash or in kind, to refer or in return for referring an individual to a person for the furnishing or arranging for the furnishing of any item or service for which payment may be made in whole or in part under a Federal or State health care program, or to refer or in return for purchasing, leasing, ordering, or arranging for or recommending purchasing, leasing, or ordering any good, facility, service, or item for which payment may be made in whole or in part under the Program.
I have never been convicted of a Program-related crime.
I have never been found guilty of child, patient or elder abuse (physical, sexual, financial or mental) in any jurisdiction.
I have never been convicted of any crime related to health care fraud.
I have never been convicted of any crime related to the unlawful manufacture, distribution, prescription, or dispensing of a controlled substance.
I have never been convicted of any crime related to fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct.
I have never been convicted of any crime related to obstruction of an investigation.
I have never had a professional license, registration or certificate ("License") revocation or suspension or lost such a License or the right to apply for or renew such a License, for reasons related to professional competence, performance, qualification, discipline, debarment, sanction, exclusion or financial integrity.
I have never surrendered any License while a formal disciplinary proceeding was pending against me before a regulatory authority and the proceeding concerned professional competence, performance, qualification, discipline, debarment, sanction, exclusion or financial integrity.
I have never been excluded or suspended under a Federal or State health care program or Federal or State procurement or entitlement program.
I have never been convicted of fraud, kickbacks, and other prohibited activities under the Program.
I do not or have not ever, nor has an immediate family member, had control of or interest in an entity that has been convicted of fraud, kickbacks, and other prohibited activities under the Program.
I have never been assessed a civil monetary penalty under sections 1320a-7a, 1320a-7b or 1320a-8 of Title 42 of the United States Code.
I have never failed to disclose required information or failed to fully and accurately disclose the required information in any dealings with the Program.
I am currently not in default on any State or Federal education loan or scholarship obligations and immediately notify the Company if, for any reason, I default on any such obligation.
I am currently not in default on any child support obligations and will immediately notify the Company if, for any reason, I default on any such obligation.
I have received and read the Company’s Conflict of Interest Policy. I understand the policy, my duties and responsibilities to comply with its provisions, and the consequences of non-compliance. I am in compliance with the policy, know of no violation of or deviations from the policy, have raised all issues concerning actual or potential conflicts of interest in writing with the Human Resources Director, the Compliance Officer or Corporate Counsel, as appropriate.