Downstream Entity (Subcontractor)

This attestation is for newly contracted Delegated Vendors only.

Please submit within 90 days of contracting.

Questions or concerns regarding this attestation should be directed to MedicareFDR@hpplans.com.

First Tier Contact Information

Organization Name *

Organization Address *

Organization Address (line 2)

City *

State *

Zip Code *

Organization's Authorized Representative *

Organization's Authorized Representative's Phone Number *

Organization's Authorized Representative's Email Address *

Section I

Downstream Entity (Subcontractor)

We do not have subcontractors

Our organization does not have any subcontractors that perform administrative and/or healthcare services for our Medicare beneficiaries.

If you check the box above, you may click Submit. If you do use subcontractors, please provide information on each below before clicking submit.

Section II

Downstream Entity (Subcontractor) #1

First Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

City *

State *

Zip Code *

Describe First Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *

Downstream Entity (Subcontractor) #2

Second Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

City *

State *

Zip Code *

Describe Second Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *

Downstream Entity (Subcontractor) #3

Third Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

City *

State *

Zip Code *

Describe Third Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *

Downstream Entity (Subcontractor) #4

Fourth Subcontractor Name *

Subcontractor Address *

Subcontractor Address (line 2)

City *

State *

Zip Code *

Describe Fourth Subcontractor functions as they relate to providing administrative and/or healthcare services on behalf of HPP to our Medicare beneficiaries. *