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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 by BlueCross BlueShield of Western New York within five (5) business days, you will not be eligible to participate in Medicare Advantage health plans. 

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Full Name
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Name of office you are representing
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Address of office you are representing

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

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