Provider Attestation

Arkansas Health & Wellness provides several self-led provider trainings. This is an annual training that is offered to every provider and is available 24/7 on the Provider Training Page. After completion of the training, providers will then need to complete the form below.

Practice Name *

TIN *

Practitioner Name *

Practice Phone Number *

What type of training did you attend? * Cultural Competency Training Secure Provider Portal Quick Start Guide Special Needs Plan Model of Care Self-Study Program

The year attestation completed *

Check box for attestation * Attest

Electronic Signature *