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Please complete all applicable fields below to certify that you have read the training document. Your submission indicates that you understand that Tufts Health Plan is relying on this certification to make submissions to state and federal regulators. If you do not submit the information below, you will not receive credit for fulfilling your training requirement.

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* 1. First name:

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* 2. Last name:

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* 3. Title:

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* 4. Organization:

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* 6. Provider NPI, if applicable:

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* 7. Provider Tax ID Number (TIN), if applicable:

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