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Thank you for reviewing and completing the Provider Education Webinar. Please take a moment to fill out the survey below. 

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* 1. Tax identification number (TIN)

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* 2. Name

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* 3. Title

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* 4. Practice/organization name

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* 5. Practice/organization ZIP Code

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* 6. Plan assigned provider ID

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* 7. Email address

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* 8. Phone number

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* 9. For additional training needs or follow-up, please call your Account Executive or send an email to ProviderCommunicationsCHC@amerihealthcaritas.com. Please remember to include your preferred method of contact.

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* 10. Comments/suggestions