Name: Amida Care, Inc.
Address: 14 Penn Plaza, 2nd Floor, New York, NY, 10122
Telephone: (646) 757-7000

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I hereby certify all staff have completed cultural competency training for 2022. 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*

Delegate Name*

Organizational TIN*

Number of Providers*

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