Cultural Competency Attestation

Attestation of Training Completion for HealthChoice and/or MMAI Participating Providers

Please fill each form below for the annual trainings.

Cultural Competency Attestation

Provider Name *

Group Name

NPI *

TIN *

Please list additional individuals in your organization that have completed the trainings. Use multiple forms for each training if necessary.

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Provider Name

NPI

TIN

Please Check Box. *

The undersigned Organization/Person (“Organization/Person”) certifies and attests that as a provider or provider entity (e.g., hospital, clinic, etc.) or as a subcontractor or affiliate (as such terms are defined by the Department of Healthcare and Family Services (HFS)), it has obtained and/or conducted required training for it and for all of its personnel and employees, as applicable, (including the Chief Executive, senior administrators or managers, and governing body members), as required for the provision of services under the contracts with the managed care organizations operating Medicaid plans for HealthChoice Illinois and/or through the Medicare–Medicaid Alignment Initiative (MMAI).

Please Check Box. *

In addition, the Organization/Person certifies and attests that it has required its subcontractors and/or affiliates and downstream entities to certify and attest that they have obtained and conducted, as applicable, the required training for all personnel and employees, as applicable. Upon request by the State of Illinois or CMS, the Organization/Person will furnish training logs, as well as certifications or attestations it obtains from its downstream entities to validate that the required training was completed.