1.Practice Information

Provider, Group or Facility Name

Address 1

Address 2

City

State

Zip

County

Email Address

Phone Number

Fax Number

Tax ID Number

2.For individual providers completing this attestation, as a provider who cares for AmeriHealth Caritas Pennsylvania beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas Pennsylvania Depression e-Learning training.

Provider Name

Date

3.For an authorized representative of a group or facility completing this attestation-as an authorized representative of a group or facility who cares for AmeriHealth Caritas Pennsylvania beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas Pennsylvania Depression e-Learning training.

Name

Title

Date

4.Please list the providers names in your group or facility who have completed the AmeriHealth Caritas Pennsylvania Depression e-Learning Training.

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

5.I would like to be invited to future provider training seminars.

Yes

No

6.I would like to receive AmeriHealth Caritas Pennsylvania news updates direct to the email provided above.

Yes

No

7.I would like to receive in-person behavioral health training from a clinical educator.

Yes

No