Certificate of Receipt

I have been provided with Internet access to the following documents:

  1. University of Florida Billing Compliance Plan .pdf (Adobe PDF Document) (05/08); (https://med.jax.ufl.edu/compliance/documents/billing_compliance_plan_05-08.pdf)
  2. University of Florida Teaching Physician Billing Policy .pdf (Adobe PDF Document) (03/20); (https://med.jax.ufl.edu/compliance/documents/UF-teaching-physician-billing-policy.pdf)
  3. University of Florida Code of Conduct .pdf (Adobe PDF Document) (02/21); (https://med.jax.ufl.edu/compliance/documents/Code_of_Conduct.pdf)
  4. Billing Compliance and Corporate Responsibility Hotline .pdf (Adobe PDF Document) (02/21); (https://med.jax.ufl.edu/compliance/documents/comp_hotline.pdf)
  5. Remedial and Disciplinary Action Memo .pdf (Adobe PDF Document) (01/17); (https://med.jax.ufl.edu/compliance/documents/remedial_and_disciplinary.pdf)
  6. Federal and State False Claims Laws .pdf (Adobe PDF Document) (02/21); (https://med.jax.ufl.edu/compliance/documents/UFHR-514-False-Claims-Laws.pdf)
  7. Departmental Compliance Leaders (https://med.jax.ufl.edu/compliance/dept/)
  8. Certificate of Receipt (https://med.jax.ufl.edu/compliance/receipt/)

By completing and returning this certification, I acknowledge that it is my responsibility to review and comply with the standards set forth in these documents and that I am aware of avenues available to me to resolve any uncertainty with regard to these requirements. Further, I promptly will report any potential violation of which I become aware to the appropriate Compliance Leader or the Office of Compliance. I understand that any violation of these policies and procedures may be grounds for corrective or disciplinary action, up to and including discharge from employment.

Instructions

Please complete the form below and click the "Submit" button. The completed certificate will be sent to the Office of Compliance. If you would like to be sent a copy of this certificate, check the appropriate box below. If you encounter problems in electronically submitting this form, you may print a copy of the completed certificate and fax it to the Office of Compliance at (904) 244-5323.

Certificate of Receipt Form

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This is a printed copy of the Certificate of Receipt form at https://med.jax.ufl.edu/compliance/receipt/ Please make sure all above required fields are filled out and fax a copy of this form to the Office of Compliance at (904) 244-5323.

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