Draft Attestation Form

Option 1 – All residents for a specific physician

I, name, affirm that for residents that have spent a training rotation at my practice, I spent at least 90 percent of my time with respect to those residents in patient care activities.

Option 2 – All residents for all physicians in a specific practice

I, name, affirm that for residents that have spent a training rotation at my practice, I, and my practice partners spent at least 90 percent of my time with respect to those residents in patient care activities.

Option 3 – Each individual resident for each specific physician

I, name, affirm that while Resident X spent a training rotation at my practice, I spent at least 90 percent of my time with respect to this resident in patient care activities.

Option 4 – Each individual resident for all the physicians in a specific practice

I, name, affirm that while Resident X spent a rotation in my practice, I , and my practice partners, spent at least 90 percent of our time with respect to this resident in patient care activities.