Offshore Subcontractor Attestation

This attestation is for offshore subcontractors  only.

First Tier Contact Information

*Indicates required field

Part I. Jefferson Health Plans Approval Information
Have you received Jefferson Health Plans' approval for offshore subcontracting? *

If you answered “no”, please obtain approval from Jefferson Health Plans before submitting this form and before delegating Jefferson Health Plans -related services to an Offshore Subcontractor.

PART II. Offshore Subcontractor Information

PART III. Precautions for Protected Health Information (PHI)

Part IV. Attestation of Safeguards to Protect Beneficiary Information in the Offshore Subcontract
Offshore subcontracting arrangement has policies and procedures in place to ensure that Medicare beneficiary protected health information (PHI) and other personal information remains secure. *

Offshore subcontracting arrangement prohibits subcontractor's access to Medicare data not associated with the sponsor's contract with the offshore subcontractor. *

Offshore subcontracting arrangement has policies and procedures in place that allow for immediate termination of the subcontract upon discovery of a significant security breach. *

Offshore subcontracting arrangement includes all required Medicare Part C and D language (e.g., record retention requirements, compliance with all Medicare Part C and D requirements, etc.) *

Not Applicable

Part V. Attestation of Audit Requirements to Ensure Protection of PHI
Organization will conduct an annual audit of the offshore subcontractor. *

Audit results will be used by the Organization to evaluate the continuation of its relationship with the offshore subcontractor. *

Organization agrees to share offshore subcontractor's audit results with CMS, upon request. *