AmeriHealth Caritas North Carolina (ACNC) provides cultural competency training and access to training opportunities for all physical and behavioral health providers in our network in accordance with state and accreditation requirements. Please help us keep our records up to date by completing the following attestation for any state-required trainings you have received to support Medicaid Managed Care.

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1. Provider Orientation completion. Select all that apply:

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2. Culturally and Linguistically Appropriate Services (CLAS) Training. Select all that apply:

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3. EPSDT Training. Select all that apply:

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4. NEMT Training. Select all that apply:

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5. First and Last name (Required.)

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6. Individual  National Provider Identifier (NPI) (Required.)

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7. Company Name /Provider Office Name (Required.)

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8. Contact Email (Required.)

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9. Contact Phone Number (Required.)

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10. Specialty Type

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11. Race/Ethnicity

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12. Language(s) Spoken

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13. Signature ( First/Last name) (Required.)

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14. Today's date (Required.)

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