Partner Attestation Statement Instructions ‐ Community‐Based Organization Dear Community‐Based Organization: Attached please find the Partner Attestation Statement for the Millennium Collaborative Care DSRIP Performing Provider System (“MCC PPS”) led by Erie County Medical Center Corporation (“ECMCC”). New York State requires that we have signed authorizations from each organization in our PPS network. In order to certify your participation in our PPS, we are requesting that you complete and return the attached Attestation Statement no later than February 19, 2015. Completing the attached documents: •
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Please fill in required information electronically (in pdf format) or by hand with black ink. Please be sure to complete: •
Attestation Statement (fill in the name and title of officer, Organization name and contact info) •
Attachment A: (fill in the names of any additional organizations that are owned, controlled or affiliated with your organization) Please have an authorized officer of your Organization sign and date the Attestation Statement.
Returning the documents: •
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Please scan the completed documents and email to [email protected] Subject Line should read: “[Organization Name} Attestation Statement” If you are unable to scan and email the documents, please mail to: Millennium Collaborative Care PPS 462 Grider Street Buffalo, NY 14215
Attn: Juan Santiago
Questions/Comments: If you have questions, comments or concerns regarding the completion of the Attestation Statement, please call or email: Juan Santiago | (716) 898‐5296 | [email protected] Thank you for participating in the Millennium Collaborative Care PPS. Partner Attestation Statement – Community‐Based Organization The undersigned individual is an authorized signatory of ______________________________________ (the “Organization”). By executing this Partner Attestation Statement, the undersigned confirms that he or she has the requisite authority to act on behalf of the Organization and the affiliated organizations listed in Attachment A and confirms that the Organization and affiliate organizations listed in Attachment A agree to participate in the Delivery System Reform Incentive Payment Program (“DSRIP”) Performing Provider System (“PPS”) known as the Millennium Collaborative Care PPS (“MCC PPS”) led by Erie County Medical Center Corporation (“ECMCC”). By signing this Partner Attestation Statement, the Organization formally consents on behalf of itself and the affiliated organizations listed in Attachment A to participation in the MCC PPS and authorizes MCC PPS and ECMCC to list the Organization as a member of the MCC PPS. Signature: _____________________________________ Print name: ____________________________________ Title: _________________________________________ Date: _________________________________________ Name of Organization: ___________________________ Organization Address: ___________________________ Organization Phone: ____________________________ Organization Email: _____________________________ ATTACHMENT A The following organizations are owned, controlled or legally affiliated with _____________________________________ and will participate in the Millennium Collaborative Care PPS led by Erie County Medical Center Corporation. Organization Name Address
Legal Affiliation to Organization