Keystone First - CHIP 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 Code

E-mail Address

Phone Number

Tax ID Number

Question Title

* 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.

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 Keystone First - CHIP beneficiaries, I hereby attest that I have completed the Keystone First - CHIP 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 Keystone First - CHIP 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