Carolina Complete Health Provider Training Attestation

New Provider Orientation, Cultural Competency, EPSDT, and Compliance annual trainings.

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* 1. Please indicate your practice-type:

Primary Care

Specialist

Ancillary

Hospital

Health Department

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* 2. Group Name

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* 3. TIN(s) for the practice/agency

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* 4. Your name (First, Last)

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* 5. Title/Role

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* 6. Email

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* 7. Attestation of attendance

By checking this box, I attest that I, or a member of the practice staff, have completed the Carolina Complete Health New Provider Orientation, Cultural Competency, EPSDT, and Compliance annual trainings

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* 8. Date you completed trainings

Date / Time

Date

Carolina Complete Health Provider Training Attestation

New Provider Orientation, Cultural Competency, EPSDT, and Compliance annual trainings.

Question Title

* 1. Please indicate your practice-type:

Question Title

* 2. Group Name

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* 3. TIN(s) for the practice/agency

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* 4. Your name (First, Last)

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* 5. Title/Role

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* 6. Email

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* 7. Attestation of attendance

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* 8. Date you completed trainings

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* 9. Please provide feedback on how we can improve your training experience