Please submit one monthly attestation following your organization’s routine exclusion screening for each calendar month, unless otherwise agreed to by Fallon.

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Why we ask for an attestation of your exclusion screenings

The Centers for Medicare & Medicaid Services (CMS) requires Fallon Health's first tier, downstream and related entities (FDRs) to screen and document the following against all applicable exclusion databases:

  • all employees, volunteers, contractors and governing body members prior to hire or appointment,
  • downstream and related entities prior to contracting, and
  • all individuals and entities monthly thereafter.

Because Fallon Health is ultimately responsible for ensuring this requirement is being met by our FDRs, we kindly request your assistance in providing us with this information on a monthly basis. 

Who must be screened against the exclusion databases

  • Employees: Includes part-time, full-time, temporary, and contracted employees and volunteers. For purposes of this attestation, you need only report on individuals working directly or indirectly on your organization's contract with Fallon Health.

  • Governing body members: The group of individuals at the highest level of governance of an organization, such as the Board of Directors or the Board of Trustees, who formulate policy and direct and control the organization in the best interest of the organization and its clients. As defined in the Medicare Managed Care Manual, Chapter 21, governing body does not include C-level management such as the Chief Executive Officer, Chief Operations Officer, Chief Financial Officer, etc., unless persons in those management positions also serve as directors or trustees or otherwise at the highest level of governance of the organization.


Submit your entity’s/organization’s attestation here

Who are you submitting for?





When did you perform screening for the audiences below?

If applicable:

What were the results of your screening?



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