TotalCare (D-SNP) Model of Care Training Attestation Form

Attestation Statement
In accordance with the requirements of the Centers for Medicare & Medicaid Services (CMS) under 42 C.F.R. §§ 422.152(g), 422.107, and Chapter 5, Section 40 of the Medicare Managed Care Manual, as well as the California Department of Health Care Services (DHCS) D-SNP Policy Guide, all providers and entities participating in the TotalCare (HMO D-SNP) Dual Eligible Special Needs Plan (D-SNP) network are required to complete annual training on the Plan’s approved Model of Care (MOC).

By submitting below, I hereby attest on behalf of myself and/or the organization identified above that:

1. I (and/or all employed/contracted providers and staff who interact with TotalCare (HMO D-SNP) members) have completed the required Model of Care Training provided by TotalCare (HMO D-SNP) for the current calendar year.
2. I understand that completion of this training is a condition of participation in the TotalCare (HMO D-SNP) network.
3. Documentation of completion is maintained and available for review by TotalCare (HMO D-SNP) upon request.
4. I acknowledge that failure to comply with this requirement may impact my/our continued participation in the TotalCare (HMO D-SNP) network.