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1-855-GO-AMIDA
Don’t Lose Your Medicaid Benefits -
Act Now
About Us
About Us
Our Sponsors
Our Model of Care
20 Years of Service
Advocacy and Research
Support Our Work
Corporate Compliance
Careers
Our Plan
Medicaid Live Life Plus
Your Care Team
Provider Network
Pharmacy
Sexual Health and HIV Prevention Services
Dental and Vision
Behavioral Health
Children’s Services
Transgender Health / TGNB
Joining the Plan
FAQs
For Members
Member Programs and Services
Find a Provider
Member Handbook
Health Information
Exchange
My Amida Care App
Healthy Rewards
Live Well
Live Your Life Undetectable
Live Your Life Wellness Program
Member Voices
Member FAQs
For Providers
Provider Services
Utilization Management
Pharmacy Information
Restricted Recipient Program
FAQS
Find a Provider
Joining the Provider Network
Provider Resources
Cultural Competency Training Attestation
Resources
Health Resources
Publications
Media Center
Speakers Bureau
Who We Are
Amida Care News
Blog
Media Coverage
Press Releases
Media Tools
Contact
How to Reach Us
Report Fraud
-
A
+
A
Language
English
Spanish
1-855-GO-AMIDA (1-855-462-6432, TTY 711)
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November 10 2020
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Medicaid Cultural Competency Training Certification
Individual Certification
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I hereby certify Amida Care participating providers have completed cultural competency training this year or in the last 12 months. I acknowledge this training and certification is required annually by the New York State Department of Health. I declare the above statement is true and accurate to the best of my knowledge. Additionally, this will confirm I hold the authority to complete this certification.
Provider Tax ID Number
*
Provider Information
*
Provider First Name*
Provider Last Name*
NPI Number* (e.g., 1234567890)
Information completed by
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First Name*
Last Name
Email Address*
Relationship to above-named provider (e.g., self, office manager, nurse, other)
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Medicaid Cultural Competency Training Certification
Group Certification
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*
I hereby certify all staff have completed cultural competency training for this year or in the last 12 months. I understand this certification is required annually by the New York State Department of Health. I confirm new providers/staff who join our group will complete the Medicaid Cultural Competency Training and the group will submit an updated provider list and certification upon request by the Plan. I declare that the above statement is true and accurate to the best of my knowledge. Additionally, this will confirm that I hold the authority to make this certification.
Name of Authorized Person
*
First Name*
Last Name
Email Address*
Title of Authorized Person
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Group / Vendor / Delegate Name
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Organizational TIN
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Number of Providers
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