Attestation form for "Building Culturally Competent Healthcare: Training for Healthcare Providers and Staff"

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This is an attestation of completion of the Provider and Staff training video series "Building Culturally Competent Healthcare" from Molina Healthcare. The training can be found here: https://www.molinahealthcare.com/providers/ca/medicaid/resource/cme.aspx

By checking the relevant fields and writing my name below, I attest that I have completed this training.

I am a provider in: *

I completed the following training modules (Please check all that apply): *

Module 1: Introduction to Cultural Competency

Module 2: Health Disparities

Module 3: Specific Population Focus – Seniors and Persons with Disabilities

Module 4: Specific Population Focus – LGBTQ and Immigrants/ Refugees

Module 5: Becoming Culturally Competent

Other:

Required

Provider/Staff Name *

Clinic/Office Name and Address

Group Tax Identification Number (TIN)

Provider Email Address

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