229.382.7120 / 800.648.1935
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Annual Vendor Certification

Annual Vendor Certification

* required info
*Insert Name of Company

(hereinafter the “Company”), hereby:

1. Acknowledges receipt of Tift Regional Medical Center’s Compliance Program and agrees to read the Program, Code of Conduct and any specific compliance policies and procedures forwarded to the Company;

2. Certifies and represents that the officers or directors of the Company have not been convicted of any crime related to healthcare;

3. Certifies and represents that the Company is not debarred, excluded or otherwise ineligible to participate in any state or federal healthcare program for the provision of items or services for which payment may be made by a state or federal healthcare program;

4. Certifies that the Company has not contracted with any employee, contractor, agent, or vendor knowing that the contracting party is excluded from participation in any state or federal healthcare program;

5. Acknowledges awareness of Tift Regional’s Helpline and the availability of this Helpline to employees of the Company to report matters to Tift Regional related the work done for Tift Regional;

6. Certifies and represents that the Company shall participate and adhere to Tift Regional’s Compliance Program in connection with performing services pursuant to this Agreement, including immediately investigating any report or indication of errors or wrongdoing that results in overpayment of funds to Tift Regional or may create liability to Tift Regional or to the Company for work done by or for Tift Regional and shall report such findings to Tift Regional; and

7. Agrees to make all employees directly involved in providing services or products to Tift Regional aware of the above certifications and acknowledgments.

Tift Regional Medical Center’s Compliance Program requires that all vendors make annual certifications. Please complete the information and submit as directed.

By return of this e-mail, the sender represents and warrants that he/she is an authorized representative of the Vendor and that the Vendor thereby executes the Tift Regional Medical Center’s Vendor Certification form as of the date of the return e-mail. The return e-mail must contain the sender’s name and title and the Vendor’s name.

*Name of Company
*Vendor Number(s)
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Tift Regional Medical Center
901 E. 18th Street, Tifton, Georgia 31794   229-382-7120 or 800-648-1935