Keystone First Community HealthChoices Missed Visit and Critical Incident Reporting Training Attestation

Please read the following attestation and complete the electronic signature form below.

I, the undersigned, certify on behalf of myself or my organization/agency that I have reviewed and completed the Missed Visit and Critical Incident Reporting Training.

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* 1. Name

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* 2. Organization/agency name

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* 3. Preferred method of contact

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* 4. Additional training needs or follow-up contact by your Account Executive

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* 5. Tax identification number (TIN)

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* 6. I confirm that I understand the missed shift reporting information and attest that missed shift reporting requirements are incorporated into the above named organization’s reporting process.

Yes

No

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* 7. I confirm that I understand the EIM and Critical Incident information and attest that missed shift reporting requirements are incorporated into the above named organization’s reporting process.

Yes

No

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* 8. Comments, questions or feedback

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* 9. By entering your electronic signature, you certify that your responses above are accurate, truthful and complete to the best of your knowledge. PLEASE ENTER YOUR FULL NAME BELOW.

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* 10. DATE SIGNED

Date

Date