HOPE Update Visit (HUV) v1.02, Item Z0400

Z0400. Signature(s) of Person(s) Completing the Record

I certify that the accompanying information accurately reflects patient assessment information for this patient and that I collected

or coordinated collection of this information on the dates specified. To the best of my knowledge, this information was collected

in accordance with applicable Medicare and Medicaid requirements. I understand that reporting this information is used as a basis

for payment from federal funds. I further understand that failure to report such information may lead to a payment reduction in

the Fiscal Year payment determination. I also certify that I am authorized to submit this information by this provider on its behalf.

Signatures Title Sections Date Section Completed

A.

B.

C.

D.

E.

F.

G.

H.

I.

J.

K.

L.