Fraud, Waste and Abuse Training Attestation

Please fill out the form below to indicate completion of Fraud, Waste and Abuse training.

Provider Group *

Provider TIN(s) * Please provide any additional TINs that should be represented on this form.

TIN 2

TIN 3

TIN 4

TIN 5

Phone *

Email *

Form Completed By *

Title *

Date *

Training Confirmation * The Fraud Waste and Abuse training has been completed by the Provider above.