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 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/ AmeriHealth Caritas Pennsylvania (PA) Community HealthChoices (CHC) beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas PA/AmeriHealth Caritas PA CHC 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 AmeriHealth Caritas PA/AmeriHealth Caritas PA CHC beneficiaries, I hereby attest that I have completed the AmeriHealth Caritas PA/AmeriHealth Caritas PA 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 AmeriHealth Caritas PA/AmeriHealth Caritas PA 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 Done
