Provider Training Information

By completing this survey, you are attesting that all providers for this business have completed the required training.

Please complete the entire survey and click Done when you are finished. You will not be able to save a partially completed survey. Please note that questions 1-3 are required to submit this survey. A separate survey will need to be done for each Tax ID.

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* 1. As representative completing this survey, I hereby attest that: (1) the foregoing responses are correct and, (2) I am authorized to provide this information on behalf of this business.
This will also serve as your signature authorizing us to make these changes to the business record.

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* 2. Please enter the Business Name.

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* 3. Please enter the 9-digit Business Tax ID number. (Example format: 999999999)

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* 4. Please attest that you have taken the following courses.

  DentaQuest Provider Orientation CMS Annual Fraud Waste and Abuse Course CMS Annual Cultural Competency and Compliance Course DentaQuest Annual Provider Training
SELECT YES OR NO

T