CMS Compliance Form

My Name

My Company

Today's Date

Conflicts That I Am Disclosing

I agree to update my Conflict of Interest disclosure form annually. GrandCare will notify me when it is time to update it. I agree to update my Conflict of Interest disclosure form annually. GrandCare will notify me when it is time to update it. Yes No

I accept the Network Health Code of Conduct (posted on GrandCare Slack). I accept the Network Health Code of Conduct (posted on GrandCare Slack). Yes No

I have completed training in: general compliance; fraud, waste, and abuse; and HIPAA. I have completed training in: general compliance; fraud, waste, and abuse; and HIPAA. Yes No

I understand how to report non-compliance, FWA, and HIPAA violations, and I understand that I can report anonymously via the Network Health hotline 877-700-7020 and the Network Health link https://nh-hcc.com. I understand how to report non-compliance, FWA, and HIPAA violations, and I understand that I can report anonymously via the Network Health hotline 877-700-7020 and the Network Health link https://nh-hcc.com. Yes No

I acknowledge that the Network Health Regulatory Compliance program document (posted on GrandCare Slack) has been made available to me. I acknowledge that the Network Health Regulatory Compliance program document (posted on GrandCare Slack) has been made available to me. Yes No

I acknowledge that Network Health has a hotline number 877-700-7020 which can also be found at NetworkHealth.com. I acknowledge that Network Health has a hotline number 877-700-7020 which can also be found at NetworkHealth.com. Yes No