PCP ADA Site Visit Attestation Form

Americans with Disabilities Act

Provider Site Visit Requirements Attestation

In accordance with Section 504 of the Rehabilitation Act of 1973 and Title II of the American with Disabilities Act (ADA) of 1990, covered entities, including all health care and social service programs, must:

Provide services and programs in the most integrated setting appropriate to the needs of the qualified individual with a disability
Ensure that programs, services, activities, and facilities are accessible
Make reasonable modifications in their policies, practices, and procedures to avoid discrimination on the basis of disability, unless it would result in a fundamental alteration of the program
Provide auxiliary aids to persons with disabilities, at no additional cost, where necessary to afford an equal opportunity to participate in or benefit from a program or activity
Designate a responsible employee to coordinate their efforts to comply with Section 504 and the ADA
Adopt grievance procedures to handle complaints of disability discrimination in their programs and activities
Provide notice that indicates:
- That the covered entity does not discriminate on the basis of disability
- How to contact the employee who coordinates the covered entity's efforts to comply with the law
- Information about the grievance procedures

For more information regarding the ADA, go to the U.S. Department of Health and Human Services website

In accordance with the Pennsylvania Department of Human Services (DHS) and Centers for Medicare/Medicaid Services (CMS), we require practitioners to comply with ADA requirements.

Handicapped parking spaces with curb cuts, if applicable
Handicapped accessible restrooms
Access ramps where applicable
Access ramps to entrance of the building
Access ramps to provider office, if different entrance than building (e.g., hospital)

If a practitioner’s site does not meet ADA standards, there are reasonable alternatives to accommodate those with disabilities. These include:

Home visits
Access at another site that meets ADA requirements
Bathroom facilities elsewhere in the building that meet ADA requirements or portable bathroom facilities

PCP ADA Site Visit Attestation Form

Thank you for reviewing the above to ensure compliance with ADA requirements. It is important you complete the attestation to confirm your office has met these standards. If you have any questions please contact providereducation@jeffersonhealthplans.com.

Attestation for Tax ID Number:

Type of Attestation:

Tax ID number (For multiple Tax ID numbers, please separate each one with a comma.) Select up to 30 locations at a time that you are attesting (only select the duplicate listed location once), complete and submit the form, then return to the form to finish the remaining ADA attestation’s locations.) *

PCP ADA Site Visit Attestation Form

Attestation for Tax ID Number:

If your address does not appear under “Select Sites,” please manually enter it below.

Select Sites

Please scroll down to the bottom of the screen to complete attestation in its entirety

Date of Attestation(MM/DD/YYYY) *

Organization Name *

Select TINs: Please select the TINs associated with the manually entered address below

Office Site Address

City

Zip

First Name *

Last Name *

Job Title *

Email *

Please choose one : *

Newly Contracted Group

New Office Site

Existing Site

By checking "I Agree", I am attesting that the office site included on this form meets the requirements outlined under the American with Disabilities Act (ADA), outlined on the first page of this document. I further attest that I am a duly-authorized representative to make and submit this Attestation and that the information is accurate, correct, current and true as of the date of my signature below.

I Agree

My site location is excluded from ADA requirements

Signature of person completing this form (please fill in first and last name) *