OUTCOME AND ASSESSMENT INFORMATION SET (OASIS)

HHA Attestation for OASIS Submission Exemption

OASIS Submission is required for HHAs participating in the Medicare and/or Medicaid programs under 42 CFR §484.20 (G320), a federal condition of participation. OASIS does not apply to HHAs meeting certain exemption requirements. In an effort to facilitate submission compliance monitoring, AHCA requests the following attestation be submitted annually, or updated upon changes in exemption status.

Question Title

* Agency Information

CMS Certification Number (CCN)

HHA Florida License Number

HHA Name

Street Address

City

Zip Code

Question Title

* Exemption Statements: This HHA provides ONLY Care and services for patients

	Applies to my agency
under the age of 18	under the age of 18 Applies to my agency
receiving prenatal, antepartum and postpartum maternity services.	receiving prenatal, antepartum and postpartum maternity services. Applies to my agency
receiving unskilled care, personal care, housekeeping or chore services.	receiving unskilled care, personal care, housekeeping or chore services. Applies to my agency
for whom Medicare or Medicaid insurance is not billed (includes traditional fee-for-service or HMO/Managed Care	for whom Medicare or Medicaid insurance is not billed (includes traditional fee-for-service or HMO/Managed Care Applies to my agency

I understand OASIS submission is required, if none of the above four criteria apply.

Question Title

* Attested by:

Name of Agency Administrator (or delegate)

Phone Number

Email Address

Questions regarding this attestation should be directed to FLQIES_HELP@ahca.myflorida.com.