December 14, 2021
RE: Attestation for ADvantage certified providers of Oklahoma Human Services (OHS) and/or Oklahoma Health Care Authority (OHCA) to receive payments for retroactive rate adjustments.
______________________________________________ (print full legal name of contracted entity providing services) operating under FEI number_________________________________ does hereby attest 100% of funding received from OHS and or OHCA for the purpose of a retroactive rate adjustment based on services provided beginning January 1, 2021 shall be utilized for the following purposes:
- Employee wages and benefits
- Overtime and or hazard pay
- Recruitment or attendance bonuses
- Other incentive pay
- Health and safety costs
- Other payroll related costs
I understand documentation of compliance may be requested by OHS and or OHCA at any time and any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.
________________________________________________ _____________________
Signature of Provider or Authorized Representative Date
Please return the signed attestation agreement to:
