AmeriHealth Caritas North Carolina Cultural Competency Attestation

Provider Training Attestation

Thank you for completing the AmeriHealth Caritas North Carolina Provider Cultural Competency presentation/training. By completing this attestation, you certify that you reviewed the presentation and understand the requirements.

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* 1. Have you completed other Cultural Competency training this calendar year? If so, please provide the date and skip to Questions #10 and #11 and enter your name and the date.

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* 2. First and Last name

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* 3. Individual National Provider Identifier (NPI)

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* 4. Company Name /Provider Office Name

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* 5. Contact Email

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* 6. Contact Phone Number

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* 7. Specialty Type

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* 8. Race/Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Two or more races

Other (please specify)

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* 9. Language(s) Spoken

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* 10. Signature ( First/Last name)

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* 11. Today's date

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