Attestation of Training Completion

Please submit the following information which is required for monitoring purposes.

As a first tier, downstream or related entity, attests that is has administered apporpriate education and training to detect, correct, and prevent potential fraud, waste, and abuse, as required by the final rule issued in the Federal Register for 42CFR Parts 422 and 423 of the Medicare Program on December 5, 2007.

Your organization completed the education and training to comply with the final rule requirement. This completed Fraud, Waste and Abuse training and education was provided by .

By signing below, you attest that your organization will furnish training logs and certifications from downstream entities upon request to your local Plan Sponsors to validate that training was completed.
Your full name:
Your Title:
Organization:
Tax ID #:
Date of Training: