DSNP Training Attestation Form

DSNP Training Attestation

The DSNP MOC training is conducted annually to ensure all contracted and non-contracted medical providers and staff receive training on the DSNPs MOC as required by the Centers for Medicare & Medicaid Services (CMS). Completion of the annual MOC training is mandatory for all providers who serve Jefferson Health Plans DSNP members. It is important you complete the below attestation confirming you have completed the course. To record your completion, please check the box marked agree and submit. If you have any questions, please contact providereducation@jeffersonhealthplans.com.

Attestation for Tax ID Number:

Type of Training:

Tax ID Number (For multiple Tax ID numbers, please separate each one with a comma) *

Enter one or more 9-digit Tax ID Numbers, separated by commas (e.g - 123456789,987654321).

If your address does not appear under “Select Sites,” please manually enter it below.

Select Sites

Please scroll down to the bottom of the screen to complete attestation in its entirety.

Method of Training *

Date of Training (MM/DD/YYYY) *

Organization Name *

First Name *

Last Name *

Job Title *

Select TINs: Please select the TINs associated with the manually entered address below

Address Line 1

Address Line 2

City

Zip

Comments

Date of Attestation (MM/DD/YYYY) *

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 all appropriate staff members have received and reviewed the training materials.

I Agree