JESSUP, INC.
DECLARATION OF PROVIDER
The undersigned provider certifies the following to be true and correct:
1) This is a true and correct representation of the services and times the services were provided;
2) The provider is properly credentialed to provide such services;
3) The provider provided the services in the manner required by law and consistent to the provider's agreement with Jessup, Inc.
MEDICAID AND INSURANCE FRAUD IS A CRIME!