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Health and Wellness
Offshore Subcontractor Attestation
Offshore Subcontractor Attestation
This attestation is for offshore subcontractors only.
*Indicates required field.
First Tier Contact Information
Organization Name
*
Organization Address (line 1)
*
Organization Address (line 2)
City
*
Zip Code
*
Organization's Authorized Representative
*
Title of Representative
*
Phone Number of Representative
*
Email Address of Representative
*
Part I. HPP Approval Information
Have you received HPP approval for offshore subcontracting?
Yes
No
If you answered "no", please obtain HPP approval before submitting this form and before delegating HPP-related services to an Offshore Subcontractor. Name of HPP Representative who granted Offshore Subcontracting approval:
*
Part II. Offshore Subcontractor Information
Subcontractor Name
*
Subcontractor Country
*
Subcontractor Address (line 1)
*
Line 2
Line 3
City
*
County
State
ZIP Code
*
Describe Offshore Subcontractor functions
*
Subcontractor Effective Date
*
Part III. Precautions for Protected Health Information (PHI)
Describe the PHI that will be provided to the Offshore Subcontractor. (If not applicable, please enter "N/A" in the text box.)
*
Discuss why providing PHI is necessary to accomplish the Offshore Subcontractor objectives. (If not applicable, please enter "N/A" in the text box.)
*
Describe alternatives considered to avoid providing PHI, and why each alternative was rejected. (If not applicable, please enter "N/A" in the text box.)
*
Part IV. Attestation of Safeguards to Protect Beneficiary Information in the Offshore Subcontract
1. Offshore subcontracting arrangement has policies and procedures in place to ensure that Medicare beneficiary protected health information (PHI) and other personal information remains secure.
*
Yes
No
2. Offshore subcontracting arrangement prohibits subcontractor's access to Medicare data not associated with the sponsor's contract with the offshore subcontractor.
*
Yes
No
3. Offshore subcontracting arrangement has policies and procedures in place that allow for immediate termination of the subcontract upon discovery of a significant security breach.
*
Yes
No
4. Offshore subcontracting arrangement includes all required Medicare Part C and D language (e.g. record retention requirements, compliance with all Medicare Part C and D requirements, etc.).
*
Yes
No
Not Applicable
*
Yes
No
Part V. Attestation of Audit Requirements to Ensure Protection of PHI
1. Organization will conduct an annual audit of the offshore subcontractor.
*
Yes
No
2. Audit results will be used by the Organization to evaluate the continuation of its relationship with the offshore subcontractor.
*
Yes
No
3. Organization agrees to share offshore subcontractor's audit results with CMS, upon request.
*
Yes
No
Submit
