§455.19. Provider's statement on check. — Inbound Citations

A State plan must meet the requirements of §§ 455.13 through 455.23.

(a) Except as provided in § 455.19, 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.”