"Non-lga Local Public Entity Certification and Local Government Agency Attestation Statements for County Based Medi-Cal Administrative Activities Invoicing" - California

Non-lga Local Public Entity Certification and Local Government Agency Attestation Statements for County Based Medi-Cal Administrative Activities Invoicing is a legal document that was released by the California Department of Health Care Services - a government authority operating within California.

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  • Released on February 1, 2011;
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NON-LGA LOCAL PUBLIC ENTITY CERTIFICATION AND LOCAL GOVERNMENT AGENCY ATTESTATION
STATEMENTS FOR COUNTY BASED MEDI-CAL ADMINISTRATIVE ACTIVITIES INVOICING
Non-LGA Local Public Entity (LPE) Name:
Claiming Unit:
Fiscal Year and Quarter:
To:
I HEREBY CERTIFY under penalty of perjury that:
1. - I am the official responsible for the information contained in this invoice, for the above-named LPE,
and I am authorized to make this certification on behalf of the LPE.
2. - The information provided in this invoice is true and correct and in accordance with state and federal
law:
2.1 - Based on actual costs of providing Medi-Cal Administrative Activities (MAA) services pursuant
to Welfare and Institutions Code (W&I) Section 14132.47 and California Code of Regulations
Section 52000.
2.2 - This certification is based on actual, total expenditures made by the LPE of public funds that
meet the requirements for claiming federal financial participation pursuant to Code of Federal
Regulations Title 42, Section 433.51.
2.3 - This invoice was prepared from the books and records of the LPE in accordance with the Medi-
Cal Administrative Activities (MAA) program Policy and Procedure Letter (PPL) No. 10-007.
3. - The costs contained in this invoice have not previously been, nor will subsequently be used for
federal match in this or any other program.
4. - The public funds expended for the costs contained in this invoice do not include impermissible
provider taxes or donations as defined under Section 1903 (w) of the Social Security Act, or other
federal funds. For this purpose, federal funds do not include patient care revenue rendered under
programs such as Medicare or Medicaid.
I, the undersigned, state: That as a Financial Officer or other individual duly authorized in a resolution by the
governing board as having authority to sign on behalf of the LPE, I am authorized and designated to make this
certification for and on behalf of _______________________________________________________ (LPE name),
that the certification above hereto are true to my knowledge. I declare that the certification information is true and
correct. I understand that the making of false statements or the filing of false or fraudulent costs is punishable and
constitute violation of the Federal False Claims Act.
Signature:
________________________________________________________ Date: _____________________
: _____________________________________________
Print Name
: __________________________________________________
Title
Local Government Agency Attestation Statement:
I, the undersigned attest: That as the Local Government Agency (LGA) Coordinator, Financial Officer or
other individual duly authorized in a resolution by the governing board as having authority to sign on behalf
of the ____________________________________ (LGA Name) that the certification above hereto are true
to my knowledge. I attest that the certification information is true and correct. I understand that the making
of false statements or the filing of false or fraudulent documentation is punishable and constitute violation of
the Federal False Claims Act.
Signature: ____________________________________________________ Date: ___________________
Print Name: ___________________________________________________
Title: _________________________________________________________
Rev: 02-11
NON-LGA LOCAL PUBLIC ENTITY CERTIFICATION AND LOCAL GOVERNMENT AGENCY ATTESTATION
STATEMENTS FOR COUNTY BASED MEDI-CAL ADMINISTRATIVE ACTIVITIES INVOICING
Non-LGA Local Public Entity (LPE) Name:
Claiming Unit:
Fiscal Year and Quarter:
To:
I HEREBY CERTIFY under penalty of perjury that:
1. - I am the official responsible for the information contained in this invoice, for the above-named LPE,
and I am authorized to make this certification on behalf of the LPE.
2. - The information provided in this invoice is true and correct and in accordance with state and federal
law:
2.1 - Based on actual costs of providing Medi-Cal Administrative Activities (MAA) services pursuant
to Welfare and Institutions Code (W&I) Section 14132.47 and California Code of Regulations
Section 52000.
2.2 - This certification is based on actual, total expenditures made by the LPE of public funds that
meet the requirements for claiming federal financial participation pursuant to Code of Federal
Regulations Title 42, Section 433.51.
2.3 - This invoice was prepared from the books and records of the LPE in accordance with the Medi-
Cal Administrative Activities (MAA) program Policy and Procedure Letter (PPL) No. 10-007.
3. - The costs contained in this invoice have not previously been, nor will subsequently be used for
federal match in this or any other program.
4. - The public funds expended for the costs contained in this invoice do not include impermissible
provider taxes or donations as defined under Section 1903 (w) of the Social Security Act, or other
federal funds. For this purpose, federal funds do not include patient care revenue rendered under
programs such as Medicare or Medicaid.
I, the undersigned, state: That as a Financial Officer or other individual duly authorized in a resolution by the
governing board as having authority to sign on behalf of the LPE, I am authorized and designated to make this
certification for and on behalf of _______________________________________________________ (LPE name),
that the certification above hereto are true to my knowledge. I declare that the certification information is true and
correct. I understand that the making of false statements or the filing of false or fraudulent costs is punishable and
constitute violation of the Federal False Claims Act.
Signature:
________________________________________________________ Date: _____________________
: _____________________________________________
Print Name
: __________________________________________________
Title
Local Government Agency Attestation Statement:
I, the undersigned attest: That as the Local Government Agency (LGA) Coordinator, Financial Officer or
other individual duly authorized in a resolution by the governing board as having authority to sign on behalf
of the ____________________________________ (LGA Name) that the certification above hereto are true
to my knowledge. I attest that the certification information is true and correct. I understand that the making
of false statements or the filing of false or fraudulent documentation is punishable and constitute violation of
the Federal False Claims Act.
Signature: ____________________________________________________ Date: ___________________
Print Name: ___________________________________________________
Title: _________________________________________________________
Rev: 02-11