Certifications

4062.2 - Certifications (Rev. 1, 05-21-04) A certification attests to the accuracy of a statement or the receipt of articles or services. It is limited to identifying information and a signature. A certification may include, at a maximum, the following information: • The name, title, address, and phone number of the individual or entity making the certification; • Any number identifying the certifier, such as the provider number, physician number, social security number, license number, tax number, or health insurance number; • An identification of the article received, for instance, a benefit check; • An authorization statement which, for instance, names a representative to act on one’s behalf, or which identifies an entity to whom the information may be revealed; • The statement to be certified. The statement must be printed on the form. The certifier cannot write it. It is acceptable to have more than one certification statement printed with a line/box to be checked off by the certifier; and • A date and a signature line. Information in excess of that described above would make the form subject to OMB review and approval. Survey and Certification Related Activities