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Keystone First - CHIP Fraud Waste and Abuse Medical Provider Training Attestation
*
1.
Practice Information
(Required.)
Provider, Group or Facility Name
Address 1
Address 2
City
State
Zip Code
E-mail Address
Phone Number
Tax ID Number
*
2.
For individual providers completing this attestation: As a provider who cares for Keystone First - CHIP beneficiaries, I hereby attest that I have completed the Keystone First - CHIP Fraud Waste and Abuse Provider Training.
(Required.)
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 Keystone First - CHIP beneficiaries, I hereby attest that I have completed the Keystone First - CHIP Fraud Waste and Abuse Provider Training.
(Required.)
Name
Title
Date
*
4.
Please list the providers names in your group or facility who have completed the Keystone First - CHIP Fraud Waste and Abuse Provider Training.
(Required.)
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.
(Required.)
Yes
No
Current Progress,
0 of 5 answered
