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Kent Intermediate School District
Electronic Signature Form Medicaid School Based Services
This form is intended to record a physical copy of your signature in the event an audit is done of the documentation you have provided electronically. An electronic signature is a unique combination of your Client ID, email address and password used to access the Medicaid Service Portal. This unique combination will ensure, for audit and confidentiality purposes, that all prior, current and future work completed online was done by you. By signing this form below, I confirm that I will keep my login account name and password secure. I also confirm that, as a service provider for the School Based Services Medicaid program, I have delivered all documented services and that all service reports transmitted are true and correct. These documented services have been provided according to clinical guidelines and to the best of my ability. I have read and agree that I will adhere to the above statements.
Signature
Date
Name (please print)
Title
This document must be kept on file for audit purposes and may be audited up to seven years AFTER employment ends. Please follow your district’s procedure for uploading signed documents in TieNet. Please attach form to the staff member profile. For aides, papapros and personal care staff without accounts in TieNet, retain a copy at your district and send original to Lynette Atlman by fax or email. Secure fax number: 616-447-2440 or email to
[email protected]
Rev. 3-2015
