Medicare Advantage Programs Provider Education Information Attestation Form 

As a participating Medicare Advantage provider, it is required that you review the Medicare Education documents, and sign the attestation form within five (5) business days in order to remain compliant with CMS regulations. Should this attestation not be received byBlueShield of Northeastern New York within five (5) business days, you will not be eligible to participate in Medicare Advantage health plans. 

 

Provider Education Documents

Practitioner Office Education Attestation Statement

I,

Full name

representing the office of

Name of office you are representing

hereby attest that the office located at

Address of office you are respresenting

reviewed the documents outlined above and deem the education to have been completed to the best of my knowledge.

*
Full name of attesting physician
*
Your unique 10-digit NPI
*
*
XXX-XXX-XXXX
*
Office manager full name
*
 
 

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