Annual Vendor Certification

By submitting this form, the Vendor (hereinafter the “Company”) hereby: 

  1. Acknowledges receipt of the Southwell Ambulatory, Inc. (“SWA”) Compliance Program and agrees to read the Program, Code of Conduct and any specific compliance policies and procedures forwarded to the Company;
  2. Certifies and represents that the officers or directors of the Company have not been convicted of any crime related to healthcare;
  3. Certifies and represents that the Company is not debarred, excluded or otherwise ineligible to participate in any state or federal healthcare program for the provision of items or services for which payment may be made by a state or federal healthcare program;
  4. Certifies that the Company has not contracted with any employee, contractor, agent, or vendor knowing that the contracting party is excluded from participation in any state or federal healthcare program;
  5. Acknowledges awareness of SWA’s Compliance Helpline and the availability of this Helpline to employees of the Company to report matters to SWA related the work done for SWA;
  6. Certifies and represents that the Company shall participate and adhere to SWA’s Compliance Program in connection with performing services pursuant to this Agreement, including immediately investigating any report or indication of errors or wrongdoing that results in overpayment of funds to SWA or may create liability to SWA or to the Company for work done by or for SWA and shall report such findings to SWA; and
  7. Agrees to make all employees directly involved in providing services or products to SWA aware of the above certifications and acknowledgments.

SWA’s Compliance Program requires that all vendors make annual certifications. Please complete the information and submit as directed.

By submitting this form, the sender represents and warrants that he/she is an authorized representative of the Vendor and that the Vendor thereby executes the Southwell Ambulatory, Inc.’s Vendor Certification form as of the date of the submission.

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