The Centers for Medicare & Medicaid Services (CMS) mandate that all contracted medical providers and their staff must receive annual training about our fully integrated Dual Eligible Special Needs Plan (FIDE-SNP) Model of Care. Horizon offers our online Horizon NJ TotalCare (HMO D-SNP) Model of Care Training as an easy way for participating practices to satisfy the CMS requirement.

Instructions
1. Complete the training.
2. Complete this training attestation form. ALL fields must be populated to be considered a completed attestation.

Please only submit one attestation form per group. Horizon does not require separate attestations for each provider.
Attestations should be submitted by the individual who has the authority to sign on behalf of the entire group (e.g., practice administrator or authorized representative).
Attestation


By signing below, I attest that:
  • I am a representative authorized to speak on behalf of this practice.
  • The individuals noted on this form have completed our online Horizon NJ TotalCare (HMO D-SNP) Model of Care Training.
  • The individuals noted on this form understand the role they play in helping improve health outcomes for this most vulnerable patient population.
  • The information on this form is accurate and complete.
  • I understand that typing my name below constitutes a legal signature.

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* 1. Signatory Name

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* 2. Signatory Title

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* 3. Practice Name

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* 4. Practice Address

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* 5. Practice Email Address

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* 6. Practice Phone Number

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* 7. Practice TIN

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* 8. Practice Type 2 NPI

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* 9. Date

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Training Attendance Roster
If the practice trained as a group, one attestation form should be submitted by the individual with authority to sign on behalf of the group and the following attendance roster populated. If you have your own roster (including the Name and Type 1 NPI of each provider completing the training) proceed to question 11 to upload that document.

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* 10. Enter the Name and Type 1 NPI for each provider in your practice covered by this attestation.

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* 11. Attachment

YOU MUST CLICK "DONE" BELOW TO SUBMIT YOUR ATTESTATION TO HORIZON.

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