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I agree to keep, and disclose upon request to authorized agencies, records which disclose fully the extent of payments claimed from the services rendered to recipients of the Medicaid Program. I accept as payment in full the amount paid by the Medicaid Program for claims submitted with the exception of authorized cost sharing by recipients. I understand payment of this claim is from state and federal funds and that any false claims, statements, documents or concealment of a material fact may be prosecuted under state or federal law. This is to certify that the information submitted to obtain this payment is true, accurate and complete.

I authorize the electronic transfer of Rhode Island Medicaid payments made to the above provider NPI. I understand that I am responsible for the validity of the above information.

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