Fraud Waste and Abuse Medical Provider Training Attestation

Question Title

* 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

Question Title

* 2. For individual Providers completing this attestation: As a Provider who cares for AmeriHealth Caritas Pennsylvania/ AmeriHealth Caritas Pennsylvania (PA) Community HealthChoices (CHC) beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas PA/AmeriHealth Caritas PA CHC Fraud Waste and Abuse Provider Training.

Provider Name

Date

Question Title

* 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 PA/AmeriHealth Caritas PA CHC beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas PA/AmeriHealth Caritas PA CHC Fraud Waste and Abuse Provider Training.

Name

Title

Date

Question Title

* 4. Please list the providers names in your group or facility who have completed the AmeriHealth Caritas PA/AmeriHealth Caritas PA CHC Fraud Waste and Abuse Provider Training.

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Question Title

* 5. I would like to receive in-person Fraud Waste and Abuse Provider Training from my Account Executive.

Yes

No