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Downstream Entity (Subcontractor)

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First Tier Contact Information





















Section I.

Downstream Entity (Subcontractor)




If you check the box above, you may click submit. If you do use subcontractor(s), please provide information on each below before clicking submit.





Section II.

Downstream Entity (Subcontractor) 1

















Downstream Entity (Subcontractor) 2

















Downstream Entity (Subcontractor) 3

















Downstream Entity (Subcontractor) 4



















Please direct questions or concerns regarding this attestation to MedicareFDR@hpplans.com.