Telemedicine Attestation

I hereby certify and attest, by my signature, that all the information above is true and accurate. I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from the Lucet network.

Furthermore, I have read the Lucet Provider and Facility Manual and supplemental Telehealth materials on the Lucet website and understand the requirements for delivery of Telemedicine services. I understand it is my responsibility to comply with all Lucet requirements and state, and federal Telemedicine statutes, regulations, and guidelines. I will cooperate with Lucet during any audit to verify that I meet the above.