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) (Required.)

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2. Individual NPI (If Applicable) (Required.)

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3. Practice Name (Required.)

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4. Practice Address (Street) (Required.)

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5. City (Required.)

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6. State (Required.)

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7. Zip Code (Required.)

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8. Email Address (Required.)

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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 (Required.)

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10. Today's Date (Required.)

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