Model of Care Clinic/Practice Attestation

Model of Care Clinic/Practice Attestation

We have received and reviewed a copy of CareOregon's Model of Care Training Materials. On an annual basis and at CareOregon's request, we will provide an attestation that the Model of Care training has been conducted in accordance with CMS regulations as provided under section 1859(f)(7) of the Social Security Act.

Full Name*

Individual provider or staff who reviewed the Model of Care Training Materials

Title*

License and/or role in the clinic or practice

NPI*

Name of Clinic/Practice*

Date Signed*

Business Email Address

If possible, provide your department or team's email, rather than a personal email.

Clinic or Practice Attestation

If attesting on behalf of the clinic or practice, please provide the additional details requested.

Did the all Practice/Clinic staff receive and review a copy of Model of Care Training Materials*

Yes

Additional staff trained

Please provide a list of the additional staff trained. If a hard copy is available, it can be uploaded below.

Upload a hard copy of staff attendance list for the Model of Care training

Drag and drop files here or

Send me a copy of my responses

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