Form CMS-10175 EFI Certification Statement

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

Form Approved

OMB No. 0938-0984

ELECTRONIC FILE INTERCHANGE ORGANIZATION (EFIO)

CERTIFICATION STATEMENT

By his/her signature(s) below, the authorized official(s) of___________________________________________
(hereinafter referred to as the electronic file interchange organization, or EFIO) legally binds the EFIO to full
adherence to all of the following conditions:
1. I certify that the EFIO has the written legal authority to act on behalf of any and all providers for whom the
EFIO submits information to CMS or its agent (hereinafter collectively referred to as the Enumerator). This
legal authority includes the submission of the provider’s application for a National Provider Identifier (NPI)
and, if agreed to between the EFIO and the provider, updates and changes to the provider’s NPI data,
deactivations, and other information.
2. I certify that any and all data the EFIO submits to the Enumerator on behalf of a provider will be no more
than 12 months old from the date the provider certifies to the accuracy of the data to be submitted on
his/her/its behalf.
3. For those providers on whose behalf the EFIO submits an initial application for an NPI, I certify that the
EFIO will promptly notify via letter or e-mail each provider of the latter’s newly issued NPI or, if applicable,
the rejection of the latter’s application. I further certify that the EFIO will only disseminate a provider’s NPI
for purposes permitted under Federal or State law.
4. In situations involving providers on whose behalf the EFIO submits a request to change the provider’s existing
NPI information or to deactivate the provider’s NPI, the EFIO agrees to promptly inform the provider of the
confirmation of the change.
5. I certify that each provider on whose behalf the EFIO submits a NPI application has informed the EFIO in
writing that the provider’s information that will be submitted to NPPES is accurate and complete. This
applies to the provider’s initial application for a NPI and, if agreed to between the EFIO and the provider,
updates and changes to the provider’s NPI data, and deactivations.
6. I certify that the EFIO is duly licensed to conduct business in all States that require the EFIO to obtain such
licensure prior to conducting business in that jurisdiction.
7. I certify that the EFIO will maintain records of all correspondence and communications between itself and
all providers on whose behalf the EFIO acts in the submission of NPI data to the Enumerator, and will maintain
all electronic files and records submitted to and received from the Enumerator in the course of acting on a
provider’s behalf. I certify that the EFIO will maintain such records and files referred to in this paragraph for
a period of 7 years, unless CMS prescribes a shorter period.
I further certify that the EFIO will ensure that such records and files (including, but not limited to, the NPIs
themselves) cannot be accessed by any person or entity not authorized under Federal or State law to review them.
8. I certify that the EFIO will fully and promptly cooperate with the Enumerator upon the latter’s request in all
matters relating to the verification of any information submitted by the EFIO on behalf of any provider. This
includes promptly contacting the provider at the Enumerator’s request to obtain clarification of the
provider’s data.
9. I understand that the Enumerator, on an as-needed basis, reserves the right to require the EFIO to furnish to
the Enumerator additional or clarifying information, such as written documentation, to confirm: (1) my
authority or any EFIO representative’s authority to act on behalf of the EFIO, (2) the status of any agency
relationship between the EFIO and a provider, and (3) the EFIO’s status as a legitimate business organization.
I certify that the EFIO will furnish the Enumerator with the requested information in a prompt fashion.

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10. I certify that the EFIO has adequate procedures and resources in place to promptly handle any and all issues,
questions, and concerns raised by providers on whose behalf the EFIO is acting for purposes of submitting
NPI data.
11. I understand that CMS reserves the right to examine for auditing purposes any and all records, files, agreements,
etc., addressed in this certification statement, and in the EFIO’s possession, at any time for any reason related
to the EFIO’s submission of NPI data on behalf of providers. I certify that the EFIO will fully cooperate with
CMS in the conduct of such audits.
12. I certify that I have the legal authority to bind the EFIO to all of the terms and conditions of this certification
statement and that I am a W-2 employee and/or owner of the EFIO. I also certify that any and all representatives
of the EFIO registered with the Enumerator to submit NPI data to the Enumerator have the legal authority to act
on the EFIO’s behalf in doing so. I agree to promptly notify the Enumerator of any change in any representative’s
legal authority to submit NPI data to the Enumerator on behalf of the EFIO.
13. I certify that any and all information in any form submitted to the Enumerator by the EFIO is truthful and
correct to the best of my knowledge. If I learn that any such information so submitted was not correct, I agree
to notify the Enumerator of this immediately. I understand that any information submitted by the EFIO to the
Enumerator that any EFIO representative knows or should have known to be false or misleading, or deliberately
omits or conceals pertinent information from the Enumerator, the EFIO is subject to any and all penalties
permitted under Federal law and State law.

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ATTENTION: READ THE FOLLOWING PROVISION OF FEDERAL LAW CAREFULLY BEFORE SIGNING.
Whoever, in any matter within the jurisdiction of any department or agency of the United States knowingly
and willfully falsifies, conceals or covers up by any trick, scheme or device a material fact, or makes any false,
fictitious or fraudulent statement or representation, or makes or uses any false writing or document knowing
the same to contain any false, fictitious or fraudulent statement or entry, shall be subject to fines and/or
imprisonment (18 U.S.C. Section 1001).
To the best of my knowledge and belief, all data in this application are true and correct, and the governing
body of the EFIO has duly authorized the signature of this document.
First Authorized Official – Full Name (Print)

Title/Position

Telephone Number

Legal Business Name of EFIO

“Doing Business As ” Name of EFIO

Business Address of EFIO

First Authorized Official Signature

Second Authorized Official – Full Name (Print)

Title/Position

Telephone Number

Legal Business Name of EFIO

“Doing Business As ” Name of EFIO

Business Address of EFIO

Second Authorized Official Signature

According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number.
The valid OMB control number for this information collection is 0938-0984. The time required to complete this information collection is estimated to 3 hours per
response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. If you
have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA
Reports Clearance Officer, Baltimore, Maryland 21244-1850.
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