Medi-Cal for Kids & Teens Provider Training (EPSDT) - Other Health Plan attestation

If you have already taken this training with another Managed Care Plan - Complete the fields below

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* 1. First Name

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* 2. Last Name

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* 3. Email Address

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* 4. Provider/Group Name

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* 5. Name of the Managed Care Plan where the training was completed

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* 6. Date training was completed

Date / Time

Date

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* 7. NPI Number