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FDR Compliance Attestation

Heritage Provider Network & Affiliated Medical Groups

I.Introduction

Our records indicate that you are contracted to provide administrative or health care services to Medicare enrollees on behalf of Heritage Provider Network (HPN) and/or one or more of its affiliated Medical Groups (Groups) listed below. As such, you are required to meet the Center for Medicare and Medicaid Services (CMS) compliance requirements for first tier, downstream, and related entities (FDRs).

Heritage affiliated medical groups

II.Attestation instructions

A. Access the online attestation

Access the Online FDR Compliance Attestation by clicking here.

  1. Choose the attestation year, then enter the contracted company's Tax ID (EIN) — the FDR name and the providers registered under it are filled in automatically.
  2. Review the provider list, uncheck any that no longer apply, and add any that are missing.
  3. Confirm your contact information: name, e-mail, fax and phone.
  4. Answer all compliance questions accurately.
  5. Sign (type or draw) then select Submit attestation.

Download and save the PDF on the confirmation screen. You must maintain it and make it available during audits as evidence that all compliance requirements were met. A new attestation is required annually.

B. Complete the following attestation sections

  1. Written Compliance Policies and Procedures, Compliance Program, and Code of Conduct: Written compliance policies and procedures and code of conduct are distributed to employees and contractors who support Medicare enrollees within 90 days of hire/contract, and annually thereafter. HPN/Groups' written compliance policies and procedures, compliance program, and code of conduct are available at: https://compliance.heritageprovidernetwork.com/site/login
  2. Compliance Training: Employees and contractors who support Medicare enrollees complete required training within 90 days of hire/contract, and annually thereafter. HPN/Groups' training modules are available at: https://compliance.heritageprovidernetwork.com/site/login
  3. OIG and SAM/GSA Exclusion List Monitoring: Employees and contractors who support Medicare enrollees are checked against the applicable exclusion lists prior to hire/contract, and monthly thereafter. Individuals verified to be excluded will be immediately terminated and ineligible to work on HPN/Groups' contract. Exclusion lists are available at:
    1. OIG Exclusion List
    2. SAM/GSA Exclusion List
  4. State-specific Exclusion List Monitoring: Employees and contractors who support Medi-Cal/Medicaid enrollees (including Duals) are checked against the applicable exclusion lists prior to hire/contract, and monthly thereafter. Individuals verified to be excluded will be immediately terminated and ineligible to work on HPN/Groups' contract. Exclusion lists are available at:
    1. California Medi-Cal Exclusion List
    2. Arizona Medicaid Exclusion List
    3. New York Medicaid Exclusion List
  5. Reporting and Non-Retaliation: Maintain a policy of non-retaliation and report compliance issues to HPN/Group by calling the Compliance Hotline at 855-625-7894 (available for anonymous reporting 24/7) or emailing corporatecompliance@heritagemed.com.
  6. Record Retention: Maintain records for at least 10 years.

III.Additional resources

  1. Medicare Managed Care Manual
  2. Office of Inspector General (OIG) General Compliance Program Guidance

FDR Compliance Attestation form

1. Contracted company

Correct this if it is wrong — your account is updated with whatever you sign.

Filled in from your Tax ID — correct it if the legal name differs.

2. Applicable provider NPIs

Enter your Tax ID above to pull the providers registered under it.

Additional NPIs not listed above

3. FDR contact

4. Compliance attestations

FDR attests as follows as it relates to its Providers, board members, officers, employees (including temporary employees and volunteers), and contractors engaged in treatment, administration, or support services for Medicare enrollees:

1) Written Compliance Policies and Procedures, Compliance Program, and Code of Conduct:

Written compliance policies and procedures and code of conduct are distributed to employees and contractors who support Medicare enrollees within 90 days of hire/contract, and annually thereafter. HPN/Groups' written compliance policies and procedures, compliance program, and code of conduct are available at: https://compliance.heritageprovidernetwork.com/site/login

Please select one of the following:

2) Compliance Training:

Employees and contractors who support Medicare enrollees complete required training within 90 days of hire/contract, and annually thereafter. HPN/Groups' training modules are available at: https://compliance.heritageprovidernetwork.com/site/login

Please select one of the following for each training module:

1. General Compliance and Code of Conduct
2. Fraud Waste and Abuse (FWA) (including False Claims Act)
3. HIPAA
4. Cybersecurity Awareness
5. Phishing Awareness
6. Model of Care (MOC)
7. Cultural Competency and Linguistics (Includes: TGI, DEI, EPSDT, AIHS, WPATH)

3) OIG and SAM/GSA Exclusion List Monitoring.

Employees and contractors who support Medicare enrollees are checked against the applicable exclusion lists prior to hire/contract, and monthly thereafter.

Please select one of the following:

4) State-specific Exclusion List Monitoring.

Employees and contractors who support Medi-Cal/Medicaid enrollees (including dual enrollees) are checked against the applicable state-specific exclusion lists prior to hire/contract, and monthly thereafter.

Please select one of the following:

5) Reporting and Non-Retaliation.

Please select one of the following:

6) Record Retention.

5. Signature

Signed October 25, 2026

© 2026 Heritage Provider Network, Inc.