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Physician Attestation / Acknowledgement


Livanta, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Area 1 and Area 5, is authorized by the Medicare Program to ensure that hospitals are appropriately obtaining acknowledgment/attestation statements from physicians with new admitting privileges. Under the regulations at 42 CFR 412.46 hospitals that are paid under the prospective payment system are required to obtain only one signed acknowledgement from physicians who are being granted admitting privileges at a particular hospital. The physician must complete the acknowledgement when he or she is granted admitting privileges at the hospital, or when the physician admits his or her first patient to the hospital.

When the hospital submits a claim, it must have on file a signed and dated acknowledgement from the attending physician that the physician has received the notice specified in 42 CFR 412.46(b).

Download and complete the Physician Attestation/Acknowledgement spreadsheet using the instructions provided. Note: we require one list per facility CMS Certification Number. To ensure a smooth, problem-free submission, please use only the form provided and refrain from making any format changes. QIOs may accept electronically signed Physician Acknowledgement Statements.

Access the Physician Acknowledgement Monitoring tool to complete your submission and receive your Physician Acknowledgement Monitoring results. This tool functions best in modern browsers such as Firefox or Chrome. Functionality may be impaired when using Internet Explorer.


General Questions

Phone: 877-588-1123 and choose option 5


Technical Assistance

Phone: 877-548-2682 and choose option 4

User Guide

Download: PAM - Providers User Guide


Password must be a minimum of eight characters in length.

Password must contain both alpha and numeric characters.

Password must contain a minimum of one uppercase and one lowercase letter.

Password must contain a minimum of one special character.

Password must be changed every 45 days from the reset date.

Newly created passwords must be different than the previous 7 passwords used.