Provider Education Attestation

Thank you for completing the required training and education course. It is important you complete the below attestation confirming you have completed the course. To record your completion, please complete the required fields and submit. If you have any questions, please contact providereducation@jeffersonhealthplans.com

Tax ID Number (do not include hyphen) *

Is this a newly contracted group?

Yes

Date of Attestation *

Date of Training *

Method of Training *

Organization Name *

First Name *

Last Name *

Job Title *

Address Line 1 *

Address Line 2

City *

State *

Zip Code *

Comments

By checking the box below, I attest I have received and distributed the required training materials to all appropriate staff under the Tax Identification Number(s) entered above. I further attest that all appropriate staff members have received and reviewed the training materials.

I agree