Keystone First VIP Choice Model of Care Training

Attestation of completion of the Keystone First VIP Choice Model of Care Provider Training

This short survey will serve as an attestation to the completion of the annual Keystone First VIP Choice Model of Care Provider Training.

Question Title

* 1. Practice Information.

Provider, Group, or Facility Name:

Address:

Address 2:

City/Town:

State:

ZIP Code:

Email Address:

Phone Number:

Fax Number:

Tax ID Number:

Question Title

* 2. For individual providers completing this attestation - As a provider who cares for Keystone First VIP Choice beneficiaries I hereby attest that I have completed the Keystone First VIP Choice annual Model of Care training, which will satisfy the CMS requirement.

Provider Name:

Date:

Question Title

* 3. For provider groups or facilities completing this attestation designate an authorized provider representative - As an authorized representative of a group or facility who cares for Keystone First VIP Choice beneficiaries I hereby attest that the providers in our group or facility have completed the Keystone First VIP Choice annual Model of Care training, which will satisfy the CMS requirement.

Name:

Title:

Date:

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* 4. Number of providers in the group or facility who completed the Model of Care training?

Question Title

* 5. OPTIONAL - Please list provider's names in your group or facility who have completed the annual Model of Care training or email a list to VIPProviderComm@amerihealthcaritas.com:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

Provider's Name:

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* 6. I would like to be invited to future provider training seminars.

Yes.

No.

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* 7. I would like to receive Keystone First VIP Choice provider news updates direct to the email.

Yes.

No.

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* 8. I would like to be entered into a drawing for a $25 gift card for my office for completing the Keystone First VIP Choice Model of Care training prior to the end of the year.

Yes.

No.