General Attestation of Medical Record Loss or Destruction
The General Attestation of Medical Record Loss or Destruction mobile app allows you to replace your paper attestation form with an Android, iPhone, tablet or Windows desktop computer.
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The mobile form includes fields to document items such as records lost or destroyed, Medicaid number, provider, billing number and captures a signature. Once the mobile app is filled out a secure PDF is generated. The PDF is easy to share, and a copy is stored in your account for your medical recordkeeping records. You can also use the App Builder to personalize and customize this mobile form. Due to extenuating circumstances beyond an individual’s control, and documentation is not available in support of Medicaid claim(s). individuals can use the app to attest that the documentation was destroyed as a result of a disaster for which the State Governor issued a Disaster Proclamation in the county where the records were located. This form can only be used for documents that were partially or completely destroyed, as a result of a recent declaration of disaster by the Governor of the State.
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