Question Title

* 1. WSC Name (treating provider):

Question Title

* 2. WSC Agency Name, if applicable

Question Title

* 3. WSC Medicaid Provider ID (treating provider):

Question Title

* 4. Person Centered Planning Training completion date:

Date

Question Title

* 5. Date Completed Module 1, Introduction and Self-Determination

Date

Question Title

* 6. Date Completed Module 2, Strategies and Best Practices

Date

Question Title

* 7. Date Completed Module 3, Methods and Styles

Date

Question Title

* 8. Date Completed Module 4, State and Federal Requirements

Date

Question Title

* 9. Yes/No.  By choosing yes, I certify that I have completed Modules 1, 2, 3, and 4 in entirety on the dates specified. I understand that I must retain a copy of the certificate received for my records as documentation that the training was completed. Falsification of this information is considered fraudulent and could result in the termination of my Medicaid Waiver Services Agreement.

T