AmeriHealth Caritas North Carolina Provider Training Attestation

AmeriHealth Caritas North Carolina (ACNC) provides cultural competency training and access to training opportunities for all physical and behavioral health providers in our network in accordance with state and accreditation requirements. Please help us keep our records up to date by completing the following attestation for any state-required trainings you have received to support Medicaid Managed Care.

Question Title

* 1. Provider Orientation completion. Select all that apply:

AmeriHealth Caritas North Carolina Provider Orientation Training

Provider Orientation Training with another Prepaid Health Plan (PHP)

On demand Provider Orientation Training

Question Title

* 2. Culturally and Linguistically Appropriate Services (CLAS) Training. Select all that apply:

AmeriHealth Caritas North Carolina CLAS Training

CLAS Training with another Prepaid Health Plan (PHP)

Sexual Orientation and Gender Identity (SOGI) Course(s) from AmeriHealth Caritas North Carolina website

SOGI Training with another Prepaid Health Plan (PHP)

Other (please specify)

Question Title

* 3. EPSDT Training. Select all that apply:

AmeriHealth Caritas North Carolina EPSDT Training

EPSDT Training with another Prepaid Health Plan (PHP)

Other (please specify)

Question Title

* 4. NEMT Training. Select all that apply:

AmeriHealth Caritas North Carolina NEMT Training

NEMT Training with another Prepaid Health Plan (PHP)

Question Title

* 5. First and Last name

Question Title

* 6. Individual National Provider Identifier (NPI)

Question Title

* 7. Company Name /Provider Office Name

Question Title

* 8. Contact Email

Question Title

* 9. Contact Phone Number

Question Title

* 10. Specialty Type

Question Title

* 11. Race/Ethnicity

American Indian or Alaska Native

Asian

Black or African American

Hispanic or Latino

Native Hawaiian or Other Pacific Islander

White

Two or more races

Other (please specify)

Question Title

* 12. Language(s) Spoken

Question Title

* 13. Signature ( First/Last name)

Question Title

* 14. Today's date

Date