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Vendor Training Attestation

Complete the Attestation Form, indicating the trainings that have been reviewed. The attestation form must be completed by an authorized representative within your organization (i.e., Owner, Compliance Officer, Organization Manager/Administrator or an Executive Officer) to attest to compliance with Medicaid program training requirements.

Required fields are marked with an asterisk (*)

Training Attestation*
DOCUMENT REVIEW - My organization will comply with Medicaid program training requirements. My organization's employees, contracted personnel, providers/practicioners, and vendors who provide health care or administrative services under Medicaid and/or Medicare have reviewed the following documents:
EXCLUSION SCREENINGS - My organization will comply with Medicaid program training requirements. My organization's employees, contracted personnel, providers/practicioners, and vendors who provide health care or administrative services under Medicaid and/or Medicare have reviewed the following screening sites:
In addition, my organization agrees to maintain supporting documentation for a period of ten years and will furnish evidence of the above to Nebraska Total Care upon request for monitoring and auditing purposes.

This form will send your message to Nebraska Total Care as an email. The email is not encrypted and is not transmitted in a secured format. By communicating with Nebraska Total Care through email, you accept associated risks. Nebraska Total Care does not accept responsibility or liability for any loss or damage arising from the use of email. To ensure the safety of your protected health information (PHI), please send us a message through the Secure Member or Provider portal.