I certify, either for myself or as the authorized representative having responsibility directly or indirectly for all employees, contracted personnel, providers/practitioners, and vendors who provider healthcare or administrative services under Medicare, the ArchCare Advantage Institutional Special Needs Plan Model of Care training has been completed. I further certify that the statements herein are true and correct to the best of my knowledge. In addition, my organization agrees to maintain supporting documentation for a period of ten years and will furnish evidence of the above to ArchCare upon request for monitoring and auditing purposes.
Date of Attestation Name of Organization (if applicable) First and Last Name of the Provider: Provider's Title Full name of the Authorized person completing the Attestation on behalf of the provider, (If applicable) Authorized Representative's Title Authorized Representative's Phone Number Authorized Representative's Email Address Taxpayer Identification Number (TIN) Comments (optional)