---
kind: "section"
citation: "42 C.F.R. § 455.18"
title: "42"
number: "455.18"
heading: "Provider's statements on claims forms."
url: "https://uscodex.org/cfr/42/455.18"
---

# §455.18. Provider's statements on claims forms.

- (a) Except as provided in [§ 455.19](/cfr/42/455.19.md), the agency must provide that all provider claims forms be imprinted in boldface type with the following statements, or with alternate wording that is approved by the Regional CMS Administrator:
  - (1) “This is to certify that the foregoing information is true, accurate, and complete.”
  - (2) “I understand that payment of this claim will be from Federal and State funds, and that any falsification, or concealment of a material fact, may be prosecuted under Federal and State laws.”
- (b) The statements may be printed above the claimant's signature or, if they are printed on the reverse of the form, a reference to the statements must appear immediately preceding the claimant's signature.

## Notes

### Authority

Authority: 42 U.S.C. 1302.

### Source

Source: 43 FR 45262, Sept. 29, 1978, unless otherwise noted.