Individual Attestation Group Attestation
I hereby attest the provider listed below has completed the 2023 EmblemHealth and ConnectiCare SNP MOC training. I understand this is required by CMS. I declare the above statement is true and accurate to the best of my knowledge. I confirm I hold the authority to make this attestation.
Provider Tax ID Number:
Provider Information:
Information completed by:
Relationship to above-named provider (e.g., self, office manager, nurse, other):
*Required field
I hereby attest the providers associated with the TIN indicated below have completed the 2023 EmblemHealth and ConnectiCare SNP MOC training. I confirm new providers who join our group will complete the SNP MOC training. My organization agrees to maintain supporting documentation and will furnish evidence of the above to EmblemHealth and/or ConnectiCare upon request for monitoring and auditing purposes. I understand this is required by CMS. I declare the above statement is true and accurate to the best of my knowledge. I confirm I hold the authority to make this attestation.
Organization Tax ID Number:
Group/Organization Name:
Center ID:
Relationship to above-named group (e.g., self, office manager, nurse, other):
*Please use this spreadsheet to list each practitioner in the group who currently participates with EmblemHealth Medicare and has completed the training. Submit via email with a subject line that includes your Group/Organization name, Center ID and SNP MOC to SNPMOC_Outreach@emblemhealth.com . (Note: Listing additional practitioners does not constitute network participation.)
**Required field