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Keystone First Community HealthChoices (CHC) provides mandated annual training for our network home-and community-based services (HCBS) providers in accordance with state and accreditation requirements. You are about to complete the attestation for the required annual Provider Education Training to ensure that we have a record of your participation.

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

I, the undersigned, certify on behalf of myself or my agency that I have reviewed and completed the Provider Education Training for 2024.

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* 1. Name

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* 2. Title

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* 3. Practice/organization name

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* 4. Practice/organization ZIP Code

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* 5. Plan assigned provider ID

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* 6. Tax identification number (TIN)

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* 7. Email Address

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* 8. Phone number 

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* 9. Additional training needs or follow-up visit by your Account Executive:

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* 10. Preferred method of contact:

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* 11. 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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* 12. DATE SIGNED

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