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Fraud Waste and Abuse Medical Provider Training Attestation
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/ 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
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
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
5.
I would like to receive in-person Fraud Waste and Abuse Provider Training from my Account Executive.
Yes
No
