University of California, Davis Medical Center Confidential

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University of California, Davis Medical Center
Confidential - Protected by Evidence Code 1157
MEDICARE ATTESTATION
The Medicare Prospective Payment System requires the attending physician to sign a statement attesting the validity of
the diagnosis and procedural information. This attestation is completed for each Medicare beneficiary discharge and filed
in the medical record.
In addition to the attestation, Medicare also requires that each attending physician sign a penalty statement which will be
kept on file in the medical record department. This statement is to be authenticated upon application for appointment to
the medical staff.
Please do not hesitate to contact the Supervisor of the Health Information Management Coding Unit at 734-2850 if you
have any questions. Thank you in advance for your cooperation.
Medicare payment to hospitals is based in part on each patient's principal and secondary diagnosis and the
major procedures performed on the patient as attested to by the patient's attending physician by virtue of his/her
signature in the medical record. Anyone who misrepresents, falsifies, or conceals essential information required
for payment of federal funds, may be subject to fine, imprisonment, or civil penalty under applicable federal laws.
Date:
Attending Physician Signature
Print or Type Full Name
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