Medicare Model of Care (MOC) Training Attestation Form

Attestation * I hereby attest that I have received the Wellcare Complete 2024 Model of Care annual Provider training

Name of Individual Completing Attestation *

Group or Practitioner Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Tax ID Number(s) - Please include all Tax ID Numbers that you are representing when completing this form: *