I certify that the information above is fully accurate and contains the data I wish to be submitted to the National Plan and Provider Enumeration System.
The terms and conditions of the National Provider Identifier Submission Authorization are incorporated by reference into this Data Validation Certification.
I acknowledge and agree that I have read the terms and conditions of this Data Validation Certification and the National Provider Identifier Submission Authorization and hereby consent to the terms and conditions set forth therein.
NATIONAL PROVIDER IDENTIFIER SUBMISSION AUTHORIZATION
1. I hereby authorize Health Platforms, Inc. d/b/a Doctor.com, a Delaware corporation with its principal place of business at 85 5th Avenue, 7th Floor, New York, NY 10003, to submit National Provider Identifier (“NPI”) data on my behalf to the Department of Health and Human Services based on my profile on the Doctor.com directory.
2. I acknowledge and agree that I have reviewed my profile on the Doctor.com directory and that all information published to my profile is true, accurate, and complete as of the date of this authorization. I further acknowledge and agree that by making this authorization I am expressly agreeing to regularly review my profile on the Doctor.com directory in order to ensure that all information contained therein remains at all times true, accurate, and complete, and that I am agreeing to update my profile on the Doctor.com directory within thirty (30) days of making any change that affects any data contained in my profile on the Doctor.com directory.
3. I acknowledge and agree that I am familiar with 18 U.S.C. 1001,. I further acknowledge and agree that I am familiar with 18 U.S.C. 3571(d),
4. I acknowledge and agree that this form is being completed by a health care provider as defined at 45 CFR 160.103.5. I acknowledge and agree that I am familiar with Section 1173 of the Social Security Act.
6. I warrant and represent that I have the capacity and authority to provide this authorization to Doctor.com.
