Cultural Competency Attestation Form

Please complete the Sentara Health Plans provider acknowledgement below so that you can be credited with completion of Cultural Competency training. Your provider profile in Sentara Health Plans provider directory will be updated to reflect that you have participated in training for Cultural Competency.

 *All fields are required and are denoted with an asterisk (*) next to the field name.

I acknowledge I have completed the following course:

Which course has been completed?

What is the name of the completed course?

When was the course completed?

Is this attestation for multiple providers (5 or more)?

Your Information

First Name

Last Name

NPI

Enter ten (10) digits NO special characters

Tax ID

***

Enter 9 digit number (no dashes)

If submitting an attestation for multiple providers (5 or more) please attach a spreadsheet with each attested providers details to include the following details: First Name, Last Name, Provider NPI, Name of Completed Training, and Date CompletedYou can upload a maximum of 1 file, up to 90MB.

Cultural Competency Attestation Form

I acknowledge I have completed the following course:

Your Information

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