Training Attestation Form

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 AmeriHealth Caritas Sexual Orientation and Gender Identity Provider Training.

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* 1. First and Last Name (as provided on the practitioner information form)

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* 2. Individual NPI (If Applicable)

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* 3. Practice Name

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* 4. Practice Address (Street)

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* 5. City

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* 6. State

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* 7. Zip Code

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* 8. Email Address

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* 9. By entering you electronic signature, you certify that your responses above are accurate, truthful and complete to the best of your knowledge.

PLEASE ENTER YOUR FULL NAME

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* 10. Today's Date

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