Fraud Waste and Abuse Medical Provider Training Attestation

Question Title

* 1. Practice Information

Provider, Group or Facility Name

Address 1

Address 2

City

State

Zip Code

E-mail Address

Phone Number

Tax ID Number

Question Title

* 2. For individual providers completing this attestation: As a provider who cares for Keystone First/Keystone First CHC beneficiaries, I hereby attest that I have completed the Keystone First Fraud Waste and Abuse Provider Training.

Provider Name

Date

Question Title

* 3. For an authorized representative of a group or facility completing this attestation: As an authorized representative of a group or facility who cares for Keystone First/Keystone First CHC beneficiaries, I hereby attest that I have completed the Keystone First/Keystone First CHC Fraud Waste and Abuse Provider Training.

Name

Title

Date

Question Title

* 4. Please list the providers names in your group or facility who have completed the Keystone First/Keystone First CHC Fraud Waste and Abuse Provider Training.

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Provider Name

Question Title

* 5. I would like to receive in-person Fraud Waste and Abuse Provider Training from my Account Executive.

Yes

No