Annual Network Provider Anti-Fraud, Waste & Abuse

Training Acknowledgement & Attestation

Fraud, Waste and Abuse Prevention Training 2019

Instructions: Please watch the full video before filling out the form below. If you need additional reading time, you can pause and play the video at any time.

Please fill out the form

Instructions: After watching the video above, please sign the form attesting to have received the annually required Network Provider Anti-Fraud, Waste & Abuse Training and resources for the Medi-Cal/Medicaid program. * Please fill out all required fields

One Attestation per contracted provider please

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Annual Network Provider Anti-Fraud, Waste & Abuse
Training Acknowledgement & Attestation 

Health Plan of San Joaquin, as a licensed health care services plan regulated by the Department of Managed Health Care (DMHC) and contracted with the Department of Health Care Services (DHCS), is committed to protecting members, our network of providers, and public interests by preventing, detecting, investigating, correcting, and reporting Fraud, Waste, and Abuse (FWA). 

Under legal requirements overseen by the federal Centers for Medicare & Medicaid Services (CMS), 42 C.F.R. §422.503 and 42 C.F.R. §423.504, providers are required to either complete the FWA training offered on the HPSJ website and send HPSJ a signed attestation, or attest that you have completed another, acceptable FWA training.


Name of Contracted EntityPractice Name:
Physician NameFull Name:
Provider NPI#:
Entity/Practice Location(s) NPI#:
Address:
City
Zip Code

Please select the training option you have completed

Training Provided by(name other organization or health plan)
Training Date

Provider Name Here

, attest to having received the annually required Network Provider Anti-Fraud, Waste & Abuse Training and resources for the Medi-Cal/Medicaid program.

Provider/Authorized Signature
(Please Sign Here)
Clear Signature

Date
Title
Phone

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Posted on July 5th, 2019 and last modified on July 22nd, 2019.

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