As required by government agencies, including the Centers for Medicare & Medicaid Services (CMS) and state agencies that oversee Medicaid plans, First Tier, Downstream, and Related Entities (FDRs) that provide administrative and/or healthcare services for Medicare Parts C and D plans and/or state Medicaid plans administered by, Eye Management Inc., your organization is considered a Downstream Entity of Eye Management Inc.. This attestation is intended to be evidence that the requirements listed above were met by your organization for the current year. This training must occur initially during the new provider orientation period or the first fifteen (15) days after provider’s effective date, whichever comes first, and annually thereafter. The authorized representative of the downstream entity (i.e. contracted EMI provider) shall ensure that all providers at their practice who are delivering services to members on behalf of EMI, shall comply with the completion of annual trainings as documented herein. Records of the completion of such trainings must be maintained for at least 10 years from the date of attestation.

I certify, as an authorized representative of an entity that has a written agreement with Eye Management Inc., that the statements made above are true and correct to the best of my knowledge. Also, my organization agrees to maintain documentation supporting the statements made above. We will maintain this documentation in accordance with federal regulations and our contract with Eye Management Inc., which is no less than ten (10) years.

My organization will produce evidence of the above to Eye Management Inc. and/or the applicable government agency upon request. My organization understands that the inability to produce this evidence may result in a request for a Corrective Action Plan (CAP) or other contractual remedies such as contract termination.