Provider Agencies Attestation Form

The Centers for Medicaid and Medicaid Services (CMS) has authorized Georgia to allow reimbursement of retainer payments for certain home and community based services during the COVID-19 Public Health Emergency but requires that all states establish “guardrails” for reimbursement. It set out specific statements that assure non-duplication of reimbursement which are described in a set of Frequently Asked Questions published on 6/30/2020 and found here: https://www.medicaid.gov/state-resource-center/downloads/covid-19-faqs.pdf. All provider agencies that received a retainer payment for any of the approved services must complete a one-time Attestation Statement indicating compliance with the CMS requirements by October 1, 2020. Complete the Attestation Statement form below: