sentences:  This exemption recognized a Governor's written request to CMS attesting that he or she is aware of the state's right to an exemption of the requirement for CRNA to be supervised by a physician trained in the provision of anesthesia.The attestation recognizes that it is in the best interests of the State's citizens to exercise this option in order to provide safe, cost effective, valuable anesthesia services and especially helps assure provision of those services to all citizens.As of March 2020, eighteen states have chosen to opt-out of the CRNA physician supervision regulation.