Keystone First Community HealthChoices (CHC) provides mandated annual training for our network home-and community-based services (HCBS) providers in accordance with state and accreditation requirements. You are about to complete the attestation for the required annual Provider Education Training to ensure that we have a record of your participation.

Please read the following attestation and complete the electronic signature form below.

I, the undersigned, certify on behalf of myself or my agency that I have reviewed and completed the Provider Education Training for 2026.

Question Title

1. Name (Required.)

Question Title

2. Title

Question Title

3. Practice/organization name (Required.)

Question Title

4. Practice/organization ZIP Code (Required.)

Question Title

5. Plan assigned provider ID

Question Title

6. Tax identification number (TIN) (Required.)

Question Title

7. Email Address (Required.)

Question Title

8. Phone number  (Required.)

Question Title

9. Additional training needs or follow-up visit by your Account Executive:

Question Title

10. Preferred method of contact:

Question Title

11. By entering your electronic signature, you certify that your responses above are accurate, truthful and complete to the best of your knowledge. PLEASE ENTER YOUR FULL NAME BELOW. (Required.)

Question Title

12. DATE SIGNED (Required.)

Date
0 of 12 answered
 

T