Novitas Solutions, the Part B MAC for eight states, says that although CMS does not require you to use any particular format for attestations, the following is an acceptable attestation if signed and dated by the medical record entry’s author:
“I (print full name of the physician/practitioner)___, hereby attest that the medical record entry for ___(date of service)__accurately reflects signature/notations that I made in my capacity as___(insert provider credentials, e.g. M.D.)__when I treated /diagnosed the above listed Medicare beneficiary.I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission, or concealment of material fact may subject me to administrative, civil, or criminal liability.”