Cultural Competency Training Attestation

Clinic/Practice Name *

Clinic/Practice Address *

Group Tax Identification Number (TIN) * Please no dashes "-"

Provider Name * Provide Full Name of Provider that Completed the Training

Practitioner NPI *

Other

Provider Ethnicity (NCQA Required) Please note this information is voluntary

Email Address * If email address differs from the person taking the training please provide both email addresses

Other

Date of Training Completion mm/dd/yyyy

I have received and reviewed Magnolia Health Plan's posted materials for the Cultural Compentency Training for Healthcare Professionals * Yes Check box below to confirm training was completed

I have completed my own Cultural Competency training course in compliance with CMS guidelines. Yes Check box below to confirm training was completed