I hereby represent that I have not been excluded from participation in any federal program and have not had any disciplinary
action taken against me or any businesses to which I am a party. I understand that falsification of this testament shall result in
rejection of this application or immediate termination of my agreement. I understand that any falsification will be reported to all
local, state and federal authorities. I agree to indemnify any party who detrimentally relied on the false information provided.
All information provided above, in connection with the credentialing of this facility is complete and accurate to the best of my
knowledge. I understand this application does not guarantee participation in the Network. I understand a variety of sources
will be used to verify the statement and documents supplied, including primary source verifications If any discrepancies are
found with the information provided in this application, I understand that this facility and any other facilities under the same
ownership, may be denied, terminated, or suspended from access to the Network. Furthermore, I certify that all application
content and supporting documents submitted are authentic and not fraudulent, and that no information has been withheld. If
any such misrepresentations and/or fraud is discovered, facility shall by liable under all applicable federal and state laws for
such act, including but not limited to the Federal False Claims Act 31 U.S.C. §§ 3729 – 3733, civil tort laws in any and all
jurisdictions in which the facility conducts business, and criminal penalty where applicable pursuant with the Office of
Inspector General. I agree that the entity accepting this credentialing application, its’ representatives, employees, and agents
shall not be liable for any act or omission related to the evaluation or verification of the information provided.