Under penalties of perjury, I attest that during the period noted above, I supervised each of the clinicians named below. I further attest that the supervision rendered by me at the designated location conforms with the currently effective state and federal regulations. In accordance with Florida regulations, I supervised the clinicians who rendered the care and treatment to the named patient. The clinician entered the medical record and I reviewed each record and signed contemporaneously. 

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.