By providing my National Provider Identifier (NPI) information, I affirm and warrant that I am the authorized individual associated with the NPI submitted. I acknowledge and understand that the information provided is accurate, complete, and true to the best of my knowledge. I further acknowledge that any false, misleading, or fraudulent representation of my status, authorization, or association with the NPI may subject me to civil and criminal penalties under applicable federal and state laws, including but not limited to fines, revocation of privileges, or other legal actions.

By submitting this information, I accept full responsibility for the accuracy of the data provided and agree to comply with all applicable regulations, policies, and legal obligations associated with the use of the NPI. I understand that failure to adhere to these terms may result in legal consequences, and I agree to hold harmless the receiving entity for any claims arising from inaccurate or fraudulent information submitted.