Sample Cover Letter/Attestation Statement

50.3 - Sample Cover Letter/Attestation Statement (Rev. 90, Issued: 02-12-15, Effective: 08-28-14- Begin with Quarter 3 in 2014.Implementation: 08-28-14- Begin with Quarter 3 in 2014) CR Implementation Report Contractor Name: Contractor/Jurisdiction Number: Date Report Submitted to CMS: [MM/DD/CCYY] Subject: Attestation Statement: Implementation of Change Requests, Qtr.__, FY__ [Include the appropriate quarter and fiscal year in the Subject line.] Attention: CMS Central Office (CO) Medicare Contractor Management Group (MCMG) In accordance with the Centers for Medicare & Medicaid Services (CMS) Change Requests 2884, 6102, and 8598, I attest that all instructions required to be implemented within Quarter __ [1, 2, 3 or 4 – select appropriate quarter] of FY __ [Enter appropriate fiscal year.] have been implemented. Exceptions are explained in Item 13 of the CR Implementation Report or attached in a separate document. Sincerely, [Name of Contractor Certifying Official.] [Title of Contractor Certifying Official.] Technical Direction Letter Compliance Report Contractor Name: Contractor/Jurisdiction Number: Date Report Submitted to CMS: [MM/DD/CCYY] Subject: Attestation Statement: Compliance with Technical Direction Letters, Qtr.__, FY__ [Include the appropriate quarter and fiscal year in the Subject line.] Attention: CMS Central Office (CO) Medicare Contractor Management Group (MCMG) In accordance with the Centers for Medicare & Medicaid Services (CMS) Change Request 8598, I attest that all instructions required to be complied with within Quarter __ [1, 2, 3 or 4 – select appropriate quarter] of FY __ [Enter appropriate fiscal year.] have been complied with. Exceptions are explained in Item 13 of the TDL Compliance Report or attached in a separate document. Sincerely, [Name of Contractor Certifying Official.] [Title of Contractor Certifying Official.]