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Corporate Compliance for Independent Contractors/Vendors

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  2. Corporate Compliance Training Video and Acknowledgement Form
    (Class A Contractors)

    Class A Contractors are defined as those who: (1) on behalf of the County, furnishes or otherwise authorizes the furnishing of Medicare and/or Medicaid health care items or services, performs billing or coding functions; or (2) provides administrative or consultative services, goods or services that are significant and material, are directly related to health care provision, and/or are included in or are a necessary component of providing items or services of Medicaid-funded programs; or (3) is involved in the monitoring of health care provided by the County.

    All Class A Contractors are required to receive training related to the County’s Compliance Program. Questions may be directed to the County's Compliance Officer (315-366-2832). Submission of this form is your legally binding acknowledgement that you have viewed the training material.

    HTML Video embed

    Please view the Training Video, then complete the Acknowledgement Form below.


  4. Electronic Signature Agreement*

    By checking the "I agree" box below, I acknowledge that:

    1. I have viewed the Compliance training video on this date.

    2. I have been provided with the opportunity to ask any questions that I may have.

    3. I acknowledge that I have received and read a copy of the Compliance Plan and the Code of Conduct.

    4. I understand that I must comply with the Compliance Plan, the Code of Conduct, all laws, regulations, policies and procedures, and guidance provided.

    5. I understand that I must report any instances of possible violations of the Compliance Plan, the Code of Conduct, laws, regulations, policies and procedures to a member of management or the Compliance Officer.

    6. I understand that Madison County maintains a hotline for confidential or anonymous reporting of possible violations of the Compliance Plan, the Code of Conduct, laws, regulations, policies and procedures.

    7. I understand that my failure to comply with the Compliance Plan, the Code of Conduct, laws, regulations, policies and procedures or to report possible violations may result in termination of the contract.

  13. Note: For agencies with multiple staff, one attestation from the agency in the form of a letter stating that your staff has received the training will suffice and should be submitted using this field.

    14. Leave This Blank:

  16. This field is not part of the form submission.