Iowa Medicaid Primary Care Physician Certification and Attestation for Primary Care Rate Increase

Provider Information:

Provider Name:

First

Last

National Provider Identifier (NPI)

10 digits

Provider Address

Tax Identification Number:

Any Tax ID of an enrolled organization associated with the NPI. There may be multiple, but list only one. Alternatively, the provider’s Social Security Number (SSN) may be used. This is for verification purposes of the authenticity of the attestation.

Primary Practice Address:

List any one of the addresses where you practice as a Medicaid Provider.

City

State

Zip:

5 or 9 digits acceptable

Email:

This address will be notified when the provider’s file has been set for the enhanced payment


Contact Phone #:	( )	-

Are you a Managed Care (MediPASS) Provider in Iowa?

YesNo

Certification:

Check specialty(s) that apply to you:

Family PracticeGeneral Internal MedicinePediatric Medicine

List any subspecialties:

American Board of Allergy and Immunology:

ABAI Certification effective date(s):

MM/DD/YY


Complete this section only if you were first board certified by either the American Board of Pediatrics (ABP) or the American Board of Internal Medicine (ABIM) and are subspecialists in Internal Medicine or Pediatrics.

American Board of Medical Specialties:

ABMS Certification effective date(s):

MM/DD/YY


Complete this section only if you have a certification from the American Board of Medical Specialties (ABMS).

American Board of Medical Specialties:

ABMS Certification effective date(s):

MM/DD/YY


Complete this section only if you have a certification from the American Board of Medical Specialties (ABMS).

American Board of Physician Specialties

ABPS Certification effective date(s):

MM/DD/YY


Complete this section only if you have a certification from the American Board of Physician Specialties (ABPS).

American Osteopathic Association

AOA Certification effective date(s):

MM/DD/YY


Complete this section only if you have a certification from the American Osteopathic Association (AOA).

Attestation (Current providers only):

I attest that I am an eligible primary care specialist or subspecialist but I am not recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA). I attest that at least 60% of my total Medicaid billings for the previous calendar year were for the Evaluation and Management (E&M) and vaccine administration codes as published in the final federal and state regulation and meet the requirements to receive the increased payment. Please type in your signature below:

Type your name

Attestation (Providers enrolled less than 1 year):

I attest that I am an eligible primary care specialist or subspecialist but I am not recognized by the American Board of Medical Specialties (ABMS), the American Board of Physician Specialties (ABPS) or the American Osteopathic Association (AOA). I attest that at least 60% of my total Medicaid billings for the previous calendar month were for the Evaluation and Management (E&M) and vaccine administration codes as published in the final federal and state regulation and meet the requirements to receive the increased payment. Please type in your signature below:

Type your name

Certification Statement:

Please certify that each of the statements below are true and accurate by selecting each box. Each statement must be certified for the attestation to be completed.

I authorize the Iowa Medicaid Enterprise (IME) to verify the information submitted in this attestation form.I certify the information contained herein is true, correct, and complete. If I become aware that any information in this attestation form is not true, correct or complete I agree to notify the IME immediately.I certify that I am the individual practitioner who is attesting to being eligible to receive the enhanced payment that is the subject of this form.I understand that any false statement, omission or misrepresentation of a material fact may result in recovery of all funds paid as a result of such false statement, omission or misrepresentation and may also result in prosecution under State and Federal laws.

470-5138 (Revised 10/13)

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