print page email page Home Offshore Subcontractor Offshore Subcontractor *Indicates required field. First Tier Contact Information Organization Name* Organization Address, Line 1* Line 2 City* State* (please select) Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Code* Organizations's Authorized Representative* Organization's Authorized Representative Phone Number* Organization's Authorized Representative Email Address* PART I. Offshore Subcontractor Information Subcontractor Name* Subcontractor Country* Subcontractor Address, Line 1* Line 2 Line 3 City* County State Postal Code* Describe Offshore Subcontractor Functions* Date Proposed/ Actual Effective Date for Offshore Subcontractor MM/DD/YYYY* PART II. Precautions for Protected Health Information (PHI) Describe the PHI that will be provided to the Offshore Subcontractor (If not applicable, please indicate N/A in the text box)* Discuss why providing PHI is necessary to accomplish the Offshore Subcontractor objectives (If not applicable, please indicate N/A in the text box)* Describe alternatives considered to avoid providing PHI, and why each alternative was rejected (If not applicable, please indicate N/A in the text box)* Part I. Attestation of Safeguards to Protect Beneficiary Information in the Offshore Subcontract Item Attestation Response I.1. Offshore subcontracting arrangement has policies and procedures in place to ensure that Medicare beneficiary protected health information (PHI) and other personal information remains secure.* Yes No I.2. Offshore subcontracting arrangement prohibits subcontractor's access to Medicare data not associated with the sponsor's contract with the offshore subcontractor.* Yes No I.3. Offshore subcontracting arrangement has policies and procedures in place that allow for immediate termination of the subcontract upon discovery of a significant security breach.* Yes No I.4. 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.)* Yes No Part II. Attestation of Audit Requirements to Ensure Protection of PHI Item Attestation Response II.1. Organization will conduct an annual audit of the offshore subcontractor.* Yes No II.2. Audit results will be used by the Organization to evaluate the continuation of its relationship with the offshore subcontractor.* Yes No II.3. Organization agrees to share offshore subcontractor's audit results with CMS, upon request.* Yes No Please direct questions or concerns regarding this attestation to MedicareFDR@hpplans.com.