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Department of Human Services Division of Mental Health and Addiction ServicesExtended Provider Agency Attestation Emergency Monthly Payment Under COVID-19 State of Emergency This document supersedes
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How to fill out extended provider agency attestation

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How to fill out extended provider agency attestation

01
To fill out the extended provider agency attestation, follow these steps:
02
Download the extended provider agency attestation form from the official website.
03
Read the instructions and requirements carefully.
04
Provide your agency details, including name, address, and contact information.
05
Indicate the type of services your agency provides.
06
Fill out the attestation statement, providing accurate and complete information.
07
Sign and date the form.
08
Submit the filled-out attestation form to the appropriate governing body or authority as instructed.
09
Keep a copy of the attestation form for your records.

Who needs extended provider agency attestation?

01
Extended provider agency attestation is required for agencies providing certain services.
02
Typically, healthcare agencies, home care agencies, social service agencies, and similar organizations need to complete this attestation.
03
It is recommended to check with the specific governing body or authority to determine if your agency requires extended provider agency attestation.
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Extended provider agency attestation is a formal declaration that verifies a provider agency's compliance with specific regulatory and operational standards.
Provider agencies that offer services under certain government programs are required to file extended provider agency attestation.
To fill out the extended provider agency attestation, you must complete the designated forms, provide accurate information regarding services provided, and submit any required documentation as instructed.
The purpose of extended provider agency attestation is to ensure that provider agencies meet necessary standards for quality, compliance, and accountability in service delivery.
The information that must be reported includes agency details, services provided, compliance with regulations, and financial disclosures as required.
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