I hereby acknowledge receipt of Provider OnBoarding’s policy in compliance with the Health Care Privacy and Portability Act and agree to abide by the terms of this policy throughout the tenure of my appointment to the Medical Staff.

"Notice to Physicians" Medicare and Champus payments to hospitals are based in part on each patient's principal and secondary diagnoses and the major procedures performed on the patient, as attested to by the patient's attending physician by virtue of his or her signature in the medical record. Anyone who misrepresents, falsifies, or conceals this essential information required for payment of Federal funds, may be subject to fine, imprisonment, or civil penalty under applicable Federal laws.

I do hereby acknowledge receipt of this notice: