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2. Corporate Compliance Program Requirements Attestation for Madison County Class A Contractors

   NOTICE:

   As required by 18 NYCRR Part 521, Madison County must ensure that all Class A Contractors comply with its program requirements. These requirements include Acknowledging receipt of the County's compliance plan and policies, Completing training on the County's Compliance Program, and Conducting monthly screenings of individuals providing services under the contract.

   Contractors must complete these steps prior to or within 30 days of signing a new contract. For multi-year contracts, compliance with these requirements must be renewed annually.

   For questions or additional information, please contact the Corporate Compliance Officer at 315-366-2832 or via email at christina.kennedy@madisoncounty.ny.gov. To report fraud, waste, or abuse, call our confidential hotline at 1-855-833-7283 anytime.

   INSTRUCTIONS: (Please read carefully)

   Step 1: Download the Training Materials. 
   CLICK HERE to access the training materials. Distribute these materials to all employees and subcontractors involved in service provision, operations oversight, or billing processes under the contract. 

   Step 2: Perform Exclusion Screenings. 
   Verify that none of the employees and subcontractors are listed on the following exclusion databases:

   • State OMIG: https://apps.omig.ny.gov/exclusions/ex_search.aspx
   • Federal OIG: https://exclusions.oig.hhs.gov/

   Step 3. Recordkeeping. For Group Attestations only: Record the names, titles, dates of training, and exclusion screening results to be uploaded as supporting documentation. You can do so by using our form CLICK HERE.   For individual attestations, you will enter this information on the form below.

   Step 4. Complete the Attestation Form. 

   1. Select your submission type 
   2. Fill in the required fields. 
   3. Click Submit.

   **ALERT**
   The individual attestation is intended only for those who have signed a contract directly with Madison County. If you are affiliated with an organization, school district, or agency, please notify them of your completed training and ensure your name is included on the group attestation submitted by an authorized representative.

4. Submission Type*

   1. Individual Attestation (See Alert)
   2. Group Attestation
6. Individual Attestation*

   I hereby acknowledge that pursuant to 18 New York Codes, Rules, Regulations Part 521, all applicable employees, contractors, agents, subcontractors and independent contractors that are subject to Madison County's Corporate Compliance Program have:

   1. Received and shall abide by Madison County's Code of Conduct and compliance policies and procedures. 
   2. Completed training on the Madison County Corporate Compliance Program. 
   3. Screened myself and all applicable individuals against the exclusion lists.

   I understand that failure to comply with the Madison County's Corporate Compliance Program, Code of Conduct, laws, regulations, policies and procedures or to report possible violations may result in termination of the contract. 

   By checking the box below, I affirm that the above statement is true and accurate to the best of my knowledge and that I hold the authority to make this attestation.

   1. I acknowledge the above.
8. First Name*
9. Last Name*
11. Tax ID or NPI*
12. Email Address*
13. Phone*
15. Date of Training*
    Date of Training
17. Result of Exclusion Screening - OIG*
    -- Select One --No MatchMatch

    Enter the result of your screening against the Federal OIG LEIE List. https://exclusions.oig.hhs.gov/

19. Date of Screening - OIG*
    Date of Screening - OIG
21. Result of Exclusion Screening OMIG*
    -- Select One --No MatchMatch

    Enter the result of your screening against the State OMIG List of Restricted and Excluded Providers. https://apps.omig.ny.gov/exclusions/ex_search.aspx

23. Date of Screening - OMIG*
    Date of Screening - OMIG
25. Group Attestation*

    I hereby acknowledge that pursuant to 18 New York Codes, Rules, Regulations Part 521, all applicable employees, contractors, agents, subcontractors and independent contractors from our organization that are subject to Madison County's Corporate Compliance Program have:

    1. Received and shall abide by Madison County's Code of Conduct and compliance policies and procedures. 
    2. Completed training on the Madison County Corporate Compliance Program. 
    3. All applicable individuals/entities have been screened against the exclusion lists. 

    We understand that failure to comply with the Madison County's Corporate Compliance Program, Code of Conduct, laws, regulations, policies and procedures or to report possible violations may result in termination of the contract. 

    By checking the box below, I affirm that the above statement is true and accurate to the best of my knowledge and that I hold the authority to make this attestation.

    1. I agree.
27. Date of Group Attestation*
    Date of Group Attestation
29. Contractor Tax ID*
31. Contractor Group/Organization Name*
33. Upload Supporting Documentation*

    You must report the names, titles, dates of training and results of exclusion screenings for all individuals in the group. 

35. Information Completed by:*
37. Email*
39. Phone*
41. Relationship to the above-named Contractor*
Leave This Blank:


43. 1. Receive an email copy of this form.
44. Email address

    This field is not part of the form submission.

45. Submit Submit and Print

* indicates a required field