Depression Attestation

Question Title

* 1. Practice Information

Provider, Group or Facility Name

Address 1

Address 2

City

State

Zip

County

Email Address

Phone Number

Fax Number

Tax ID Number

Question Title

* 2. For individual providers completing this attestation, as a provider who cares for AmeriHealth Caritas Pennsylvania beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas Pennsylvania Depression e-Learning 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 AmeriHealth Caritas Pennsylvania beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas Pennsylvania Depression e-Learning training.

Name

Title

Date

Question Title

* 4. Please list the providers names in your group or facility who have completed the AmeriHealth Caritas Pennsylvania Depression e-Learning 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 be invited to future provider training seminars.

Yes

No

Question Title

* 6. I would like to receive AmeriHealth Caritas Pennsylvania news updates direct to the email provided above.

Yes

No

Question Title

* 7. I would like to receive in-person behavioral health training from a clinical educator.

Yes

No