In cases where the provider is unable to provide documentation because the needed medical record is completely destroyed, due to disaster, the provider may submit a Disaster Attestation Letter to that effect.
In cases where the provider is unable to provide complete documentation because the needed medical record is partially destroyed, due to disaster, the provider should submit the portion of the medical record that was not destroyed and submit a Disaster Attestation Letter stating that the remainder of the medical record was destroyed.
For CERT purposes, a “disaster” is defined as any natural or man-made catastrophe which causes damages of sufficient severity and magnitude to partially or completely destroy, or delay access to, medical records and associated documentation.
Submitting a false Disaster Attestation Letter is subject to penalty of perjury. Click the link below for a copy of the attestation form. Providers who need to use this form can print and fax it to the CERT Customer Service Center.
On March 16, 2010, CMS issued CR#6698 that clarified Medicare Fee for Service signature requirements. CMS Signature Guidelines for Medical Review Purposes:
Click the link below for a copy of the attestation form. Providers who need to use this form can print and fax the form to the CERT Customer Service Center.
While this sample statement is an acceptable format, at this time, CMS is neither requiring nor instructing providers to use a certain form or format. A general request for signature attestation shall be considered a non-standardized follow-up question from the contractors to the providers so long as the contractors do not provide identical requirements or suggestions for the form or format of the attestation. The above format has not been approved by the Office of Management and Budget (OMB) and therefore it is not mandatory. However, once OMB has assigned an OMB Paperwork Reduction Act number to this attestation process, a certain form/format will be mandatory.