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 Competency 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

For Large Groups

After completing a cultural humility/competency training, download and complete the Provider Attestation Spreadsheet. Once all members of the group are added to the spreadsheet, please submit the spreadsheet to Magnolia Health Equity Department. Your completed spreadsheet will be confidential and uploaded to a secure site.