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ALAMEDA COUNTY HEALTH CARE SERVICES AGENCY Public Health Department – Administrative Services Finance-Contracts and Grant Claiming SB 12 PHYSICIAN CERTIFICATION FOR REIMBURSEMENT OF UNCOMPENSATED EMERGENCY MEDICAL SERVICES CALENDAR YEAR 2019-2020
This certification is submitted by the undersigned medical entity for reimbursement under the SB 12 Program for uncompensated emergency medical services provided in a licensed general acute care hospital in Alameda County.
The undersigned:
1. Acknowledges possession of a copy of the “SB 12 Physician Reimbursement Guidelines” and agrees to comply with the terms and conditions governing the payment of claims. 2. Certifies that he/she/entity has complied fully with the reimbursement claiming conditions as outlined in the
SB 12 Physician Reimbursement Guidelines. 3. Certifies that all other physician billing requirements, duties, and obligations, including but not limited to the preparation, maintenance and retention of service and finance records and their availability for audit, have been and will be observed. 4. Expressly acknowledges and understands that this Certification is to be filed yearly and is subject to those conditions defined in the Reimbursement Guidelines including, among others, availability of monies in the SB 12 Fund, and audit adjustments. 5. Certifies, under penalty of perjury, that the claims submitted for SB 12 reimbursement are true, accurate, and complete to the best of his/her/entity’s knowledge. 6. [Applies to Electronic Data Interchange (EDI) only] Acknowledges possession of a copy of the “EDI Trading Partner Guidelines” and the “EDI Companion Guide” and agrees to comply with the terms
governing the exchange of electronic data contained therein. Printed Name & Signature of Individual Physician, a Partner, or an Officer of the Corporation & Date
Full legal name of entity & address (type or print) DBA (if applicable and different from above) to be used for SB 12 billing & remittance address
Type of Entity: Individual Sole Proprietor Partnership Medical Corporation License Number __________________Tax ID Number (TIN) SSN EIN Billing Contact Name & Billing Company Name Billing Contact E-mail Address
Billing Contact Phone Number Billing Contact FAX Number
Hospital/Group/Affiliation
Certification Period: January 1, 2019– December 31, 2020