Provider Training Attestation

Once the Alignment Health Plan Special Needs Plan Model of Care Provider Training has been reviewed for the current coverage year, please submit an attestation on behalf of the provider group.

You can submit your attestation via our online form or fax or email.

I hereby attest on behalf of the listed Provider(s) that we have reviewed and completed the Special Needs Plan (SNP) Model of Care (MOC) Training.

The listed Provider(s) and myself understand the Model of Care and our organization's role in improving health outcomes for our most vulnerable population.

It is understood this training is required by the Centers for Medicare and Medicaid Services (CMS) for all Medicare Advantage Providers that care for SNP members.

Send your attestation via online form

We highly encourage you to use our new form. As you fill out your information, required fields are marked with an asterisk (*).

Training Information

* I am filling out this form:

For myself
For a group of people (REQUIRED: Please list all individuals under the "Additional Attestation Individuals" section below)

* Training Type:

Annual
Onboarding/Newly Contracted

* State:

* County:

Attesting Designee or Provider

* First & Last Name:

* Title:

* Organization Name:

* Phone Number:

* Email Address:

Additional Attesting Individuals

REQUIRED: If you are filling out this form on behalf of a group of individuals, please list the first and last names of each individual below who has reviewed and completed Alignment Health Plan's Special Needs Plan (SNP) Model of Care (MOC) Training. Please use a comma to separate multiple names.

* List the first and last names of additional individuals below. If you are only filling out this form for yourself, please enter “N/A”:

Optional List Submission

1. If you are having difficulty entering the names of attesting individuals in the field above, you may also complete and submit names using our Excel template.

Download Excel File

2. Fill out the fields in the Excel template, save changes to your computer, and choose that file by clicking the button.

Upload Excel file:

By clicking on submit, I hearby attest on behalf of the listed Provider(s) that we have reviewed and completed the Special Needs Plan (SNP) Model of Care (MOC) Training.

Send your attestation via fax or email

If you prefer to send your attestation via fax or email, click the button to download our PDF.

Representative Attestation

Please send the document via fax at 1-562-207-4617 or by email at QI@ahcusa.com.

Page last updated on January 05, 2024 | Y0141_24290EN_M