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* 1. Practice Information

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* 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 Fraud Waste and Abuse Provider Training.

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* 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 Fraud Waste and Abuse Provider Training.

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

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

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