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Offshore Subcontractor Attestation

*Indicates required field.

First Tier Contact Information

Have you received HPP approval for offshore subcontracting?
Yes
No
Describe Offshore Subcontractor Functions
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)
IV.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
IV.2. Offshore subcontracting arrangement prohibits subcontractor's access to Medicare data not associated with the sponsor's contract with the offshore subcontractor.
Yes
No
IV.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
IV.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
Not Applicable
Yes
No
V.1. Organization will conduct an annual audit of the offshore subcontractor.
Yes
No
V.2. Audit results will be used by the Organization to evaluate the continuation of its relationship with the offshore subcontractor.
Yes
No
V.3. Organization agrees to share offshore subcontractor's audit results with CMS, upon request.
Yes
No