Physician Certification Statement

I,{physicianName} hereby attest that the medical record entry for this order accurately reflects signatures/ notations that I made in my capacity as the care provider, when I treated/diagnosed the above listed 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.