Form Center

Corporate Compliance for Independent Contractors/Vendors

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

   All independent contractors/vendors that provide direct health and medical services (classified as "Class A Contractors") for Madison County are required to receive training related to the County’s Compliance Program. Questions may be directed to the County's Compliance Officer. Submission of this form is your legally binding acknowledgement that you have viewed the training material.

   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.

   1. I agree.
6. Electronic Signature*
8. Independent Contractor/Vendor Company Name*
10. Option: Upload document (i.e. group sign in sheet or letter)
12. Today's Date*
    Today's Date
Leave This Blank:


14. 1. Receive an email copy of this form.
15. Email address

    This field is not part of the form submission.

16. Submit

* indicates a required field