Health Care Commission Affidavit

HEALTH CARE COMMISSION AFFIDAVIT

DOCUMENT HEADER & PREAMBLE

DOCUMENT TITLE: Institutional Health Care Commission and Compensation Affidavit
EFFECTIVE DATE: [Effective Date, e.g., November 1, 2023]
JURISDICTION: State of [State], County of [County]
AFFIANT (PAYEE/RECIPIENT): [Affiant Full Legal Name], residing at [Affiant Street Address, City, State, Zip], acting in an individual capacity / as [Title] of [Affiant Entity Name].
PRINCIPAL (PAYOR/ENTITY): [Principal Organization Name], a [State of Incorporation/Organization] [Corporate Structure, e.g., Corporation / Limited Liability Company], having its principal place of business at [Principal Address].

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RECITALS & SCOPE

WHEREAS, the Principal and the Affiant have entered into, or are contemplating entering into, a professional relationship, referral arrangement, advisory agreement, or operational contract governed by applicable healthcare regulatory frameworks, including but not limited to the federal Anti-Kickback Statute (42 U.S.C. § 1320a-7b(b)), the Stark Law (42 U.S.C. § 1395nn), and state-equivalent healthcare compliance statutes;

WHEREAS, this Affidavit is executed to provide formal, verified representations and warranties regarding the terms, calculation, purpose, and arm’s-length nature of any commission, fee, or financial remuneration passing between the parties;

NOW, THEREFORE, in consideration of the mutual covenants contained herein and for other good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, the Affiant solemnly swears, deposes, and states as follows under penalty of perjury.

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COMPLETE OPERATIVE PROVISIONS

Section 1. Verification of Identity and Authority

1.1 The Affiant is over the age of eighteen (18) years, is legally competent to make this Affidavit, and has personal knowledge of the facts, figures, and representations set forth herein.
1.2 If the Affiant executes this document on behalf of a corporate entity, partnership, or other legal structure, the Affiant warrants that they are duly authorized by the governing body of said entity to bind the entity to the terms of this Affidavit.

Section 2. Nature and Purpose of Remuneration

2.1 Any and all commissions, referral fees, administrative payments, or financial considerations (collectively, "Commissions") paid or to be paid by the Principal to the Affiant are strictly compensation for bona fide, legitimate services actually performed, or authorized commercial arrangements recognized under applicable safe harbors.
2.2 The Affiant expressly affirms that no Commission paid or received is, or shall be construed as, a kickback, bribe, rebate, or direct/indirect payment for the referral of patients, ordering of tests, prescribing of pharmaceuticals, or generation of healthcare business reimbursable by federal or state healthcare programs (including Medicare and Medicaid).

Section 3. Fair Market Value and Arm’s-Length Calculation

3.1 The methodology used to calculate all Commissions is established in advance, reflects true Fair Market Value (FMV) in an arm’s-length transaction, and does not take into account the volume or value of any referrals or business otherwise generated between the parties.
3.2 The compensation structure does not exceed commercial reasonableness and is fully documented within the underlying master services agreement, fee schedule, or operational contract dated [Underlying Contract Date], attached hereto as Exhibit A.

Section 4. Regulatory Compliance and Disclosure

4.1 The Affiant warrants that they are not currently excluded, debarred, suspended, or otherwise rendered ineligible to participate in any federal or state healthcare program.
4.2 The Affiant agrees to immediately disclose to the Principal's Compliance Officer any material change in licensure, ownership, affiliate relationships, or regulatory status that could impact the validity of this Affidavit or violate applicable healthcare compliance laws.

Section 5. Audit, Record Retention, and Access

5.1 The Affiant agrees to maintain accurate, transparent, and contemporaneous books, records, and accounts of all transactions, services rendered, and Commissions received pursuant to this arrangement.
5.2 Such records shall be retained for a minimum period of [Number, e.g., ten (10)] years from the date of final payment or for the duration mandated by applicable federal and state regulatory retention schedules, whichever is longer.
5.3 The Affiant shall make such records available for inspection, audit, and reproduction by the Principal, its legal counsel, or designated regulatory authorities upon reasonable written notice.

Section 6. Indemnification and Liability

6.1 The Affiant agrees to defend, indemnify, and hold harmless the Principal, its officers, directors, employees, and agents from and against any and all claims, liabilities, losses, damages, regulatory fines, civil monetary penalties, or legal fees arising out of or resulting from any material breach of the representations, warranties, or covenants contained within this Affidavit.

Section 7. Governing Law and Severability

7.1 This Affidavit and all matters arising out of or relating to it shall be governed by, and construed in accordance with, the laws of the State of [Jurisdiction], without regard to its conflict of laws principles.
7.2 If any provision of this Affidavit is held to be invalid or unenforceable, such provision shall be modified to the minimum extent necessary to make it valid and enforceable, and the remaining provisions shall remain in full force and effect.

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STANDARD BRACKETED FILLABLE BLANKS

Instructions for drafting personnel: Prior to final execution, locate and replace all bracketed items (e.g., [Party A Name]) with precise operational data. Ensure no bracketed placeholders remain in the executed institutional document.

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FORMAL EXECUTION & SIGNATURE BLOCKS

IN WITNESS WHEREOF, the Affiant has executed this Health Care Commission Affidavit under oath as of the Effective Date written above.

AFFIANT:

Signature: ____________________________________________________
Printed Name: [Affiant Printed Name]
Title: [Affiant Title / Capacity]
Entity: [Affiant Entity Name, if applicable]
Date: [Execution Date]

NOTARY PUBLIC ACKNOWLEDGMENT:

State of [State]
County of [County]

Subscribed and sworn to (or affirmed) before me on this [Day] day of [Month], [Year], by [Affiant Full Name], who proved to me on the basis of satisfactory evidence to be the person who appeared before me.

Notary Public Signature: ________________________________________
My Commission Expires: [Expiration Date]
(Notary Seal)

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PRINCIPAL ACKNOWLEDGMENT & ACCEPTANCE:

Signature: ____________________________________________________
Printed Name: [Authorized Officer Printed Name]
Title: [Authorized Officer Title, e.g., Chief Executive Officer]
Entity: [Principal Organization Name]
Date: [Execution Date]

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STEP-BY-STEP EXECUTION & FILING GUIDE

1. Document Preparation (Word / Google Docs)

• Open the document template in Microsoft Word or Google Docs.
• Utilize the Find and Replace function (Ctrl+H / Cmd+H) to sweep the document for open bracket tokens (e.g., locate [ and replace with specific organizational data).
• Verify that all structural cross-references (such as Exhibit A citations) match actual appended contract instruments.

2. Signatory Authority Verification

• Confirm that the individual signing as Affiant holds explicit corporate authority (via corporate resolutions, operating agreements, or incumbency certificates) to legally bind the payee entity.
• Verify via the Office of Inspector General (OIG) List of Excluded Individuals/Entities (LEIE) and System for Award Management (SAM) that the Affiant has active, clear status.

3. Execution Protocol

• The Affiant must sign this Affidavit in the physical presence of a licensed Notary Public.
• The Notary Public must verify government-issued identification, administer the oath, complete the jurat section, and apply their official seal or stamp.
• The Principal’s authorized representative must countersign to acknowledge receipt and operational integration of the affidavit into the compliance file.

4. Record Retention & Compliance Archiving

• Scan the fully executed, notarized document into a secure, encrypted PDF format with searchable text (OCR enabled).
• File the digital asset within the Template Registry compliance database under the specific Vendor/Provider Master File.
• Hard copies must be physically stored in the secure Corporate Compliance Records vault for the duration specified in Section 5.2 ([Number] years).