Certification & Consent Statement
I hereby certify that all information and documentation submitted by me is true, accurate, and complete to the best of my knowledge. I affirm that I am not engaging in any fraudulent activity or misrepresentation and agree to uphold the ethics, standards, and moral expectations of the Visiting Neighbors vetting process.
I further certify that I am an active provider or plan to be through the Michigan Department of Health and Human Services (MDHHS), and that my provider number will remain active and in good standing. I understand this is position is salary based due to visiting neighbors being state funded until further notice.
I confirm that all information submitted regarding my clients, services, and provider status is truthful and provided to the best of my knowledge. I understand that any false, misleading, or fraudulent information may result in denial, termination, or legal consequences.
By signing below, I authorize Visiting Neighbors and its representatives to verify and confirm any information submitted, including provider status, client-related documentation, and supporting records as necessary.