Provider Signature Attestation Statement

WPS Medicare has received questions from providers regarding the information a provider signature attestation statement should contain. In response to these inquiries we have developed an example of a signature attestation statement to provide further guidance. While not a Medicare mandated form, for your convenience it can be completed and submitted as an attestation statement if required. Any similar statement is acceptable provided it is signed, dated, and contains sufficient information to identify the patient and date of service.