On or before January 31 of each year, a trauma physician or trauma health care practitioner who has received uncompensated care reimbursement from the Fund during the prior calendar year shall file an annual reconciliation report with the Commission. The annual reconciliation report shall include: The name, address, and telephone number of the practitioner, practice, or center; The name, address, and telephone number of the practitioner, practice, or center's contact person for the report; The name of the trauma center where care was provided; The amount of money recovered from another payer source for claims that had been reimbursed by the Fund, including: The practitioner's name providing the care; The patient's name, Trauma Registry number, Social Security number, dates of service, and total amount paid by the Trauma Fund; The source of the additional funds received; The amount of the other payment received; and The amount returned to the Trauma Fund; and A certification by an authorized designee of the practitioner, practice, or center that the facts stated in the annual reconciliation report are true and accurate.