First Choice VIP Care Model of Care Training

Attestation of completion of the First Choice VIP Care Model of Care Provider Training

This short survey will serve as an attestation to the completion of the annual First Choice VIP Care Model of Care Provider Training.

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* 1. Practice Information.

Provider, Group, or Facility Name:

Address:

City/Town:

State:

ZIP Code:

Email Address:

Phone Number:

Fax Number:

Tax ID Number:

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* 2. For individual providers completing this attestation - As a provider who cares for First Choice VIP Care beneficiaries I hereby attest that I have completed the First Choice VIP Care annual Model of Care training, which will satisfy the CMS requirement.

Provider Name:

Date:

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* 3. For provider groups or facilities completing this attestation designate an authorized provider representative - As an authorized representative of a group or facility who cares for First Choice VIP Care beneficiaries I hereby attest that the providers in our group or facility have completed the First Choice VIP Care annual Model of Care training, which will satisfy the CMS requirement.

Name:

Title:

Date:

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* 4. Please enter the number of providers who completed the Model of Care training (must be a number).

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* 5. I would like to receive First Choice VIP Care provider news updates via the email noted above.

Yes.

No.