SUBMISSION PAGE¶
Submission Certification¶
- Under the Submission Certification you are required to accept the following statements before submitting the application.
- I have read the contents of the supplication and the information contained herein is true, correct, and complete. If I become aware that any information in this application is not true, correct or complete, I agree to notify the NPI, enumerator of this fact immediately.
- I authorize the NMPI Enumerator to verify the information contained herein. I agree to keep the NPPES updated with any changes to data listed on this application form within 30 days of the effective date of the change.
- I have read and understood the Privacy Act Statement.
Penalties for Falsifying Information:¶
18 U.S.C. 1001 authorizes criminal penalties against an individual who in any matter within the jurisdiction of any department or agency of the United States knowingly or willfully falsifies, conceals, or covers up by any trick, scheme or device a material fact, or makes any false, fictitious or fraudulent statements or representations, or makes any false writing or document knowing the same to contain any false, fictitious or fraudulent statement or entry. Individual offenders are subject to fines of up to $250,000 and imprisonment for up to five years. Offenders that are organizations are subject to fines of up to $500,000. 18 U.S.C. 3571(d) also authorizes fines of up to twice the gross gain derived by the offender if it is greater than the amount specifically authorized by the sentencing
Certify Check Box:¶
A Check box stating that - I certify that this form is being completed by, or on behalf of, a health care provider as defined at 45 CR ? 160.103. This is a mandatory field.