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March 15, 2021

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March 15 2021

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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*
Group / Vendor / Delegate Name*
Organizational TIN*
Number of Providers*
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Medicaid Cultural Competency Training Certification

Individual Certification

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This field is for validation purposes and should be left unchanged.
Accept*
- 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)
Group / Vendor / Delegate Name
Information completed by*
First Name* Last Name Email Address*
Relationship to above-named provider (e.g., self, office manager, nurse, other)*
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