Entidad subordinada (subcontratista)

This attestation is for newly contracted Delegated Vendors only.

Please submit within 90 days of contracting.

Questions or concerns regarding this attestation should be directed to MedicareFDR@hpplans.com.

Información de contacto de la entidad de primer nivel

Organization Name *

Organization Address *

Organization Address (line 2)

Ciudad *

Estado *

Código postal *

Organization's Authorized Representative *

Organization's Authorized Representative's Phone Number *

Organization's Authorized Representative's Email Address *

Section I

Entidad subordinada (subcontratista)

No tenemos subcontratistas

Nuestra organización no tiene subcontratistas que lleven a cabo servicios administrativos y/o de atención médica para nuestros beneficiarios de Medicare.

Si marca la casilla anterior, puede hacer clic en enviar. If you do use subcontractors, please provide information on each below before clicking submit.

Section II

Downstream Entity (Subcontractor) #1

First Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

Ciudad *

Estado *

Código postal *

Describe First Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *

Downstream Entity (Subcontractor) #2

Second Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

Ciudad *

Estado *

Código postal *

Describe Second Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *

Downstream Entity (Subcontractor) #3

Third Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

Ciudad *

Estado *

Código postal *

Describe Third Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *

Downstream Entity (Subcontractor) #4

Fourth Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

Ciudad *

Estado *

Código postal *

Describe Fourth Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *