MODEL OF CARE TRAINING ATTESTATION
MANDATORY REQUIREMENT

As part of required CMS mandated annual training, Molina has developed the Model of Care program for Medicare SNP enrollees. The Model of Care program serves as the foundation for Molina’s care management policy, procedures and operational systems for our Medicare SNP population(s).

What Providers Need to Do

1. Complete training.
2. Complete and sign this form.
   1.  If it is a group training, one Attestation form should be submitted via e-mail by the individual with authority to sign on behalf of the group and an attendance roster must also be attached.
3. Return this form using “submit” button below or via email if submitting a roster: SWHProviderRelations@molinahealthcare.com .

This Attestation will serve as evidence of completion for Molina’s Model of Care Provider training.

 

Model of Care Training Attestation Calendar Year

I have received and reviewed the written materials for the Model of Care training.

Print Provider Name:
Provider Primary Specialty:
Print Clinic/Practice Name:
Clinic/Practice Address:
Signature: Date:
TIN: NPI:
Provider Contact Name: Tel #:
Select a file:
Attached file: :

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