Provider Personnel Requirements Attestation

PROVIDER PERSONNEL REQUIREMENTS – ATTESTATION

I, ______, attest that ______staff members serving Community Behavioral Health (CBH) Members have each met the following requirements:

·  The required education for the respective position

·  The required experience for the respective position

·  Completed all CBH mandatory trainings (within 90 days of hire, and ongoing as required)

·  Completed all level of care specific required trainings (within respective time frames at hire and ongoing)

·  Submitted a CPR certification appropriate to the level of care, including CPR certification for all physicians

·  Submitted a valid PA Criminal History Report

·  Submitted a valid PA Child Abuse Clearance (for staff likely to have contact with children per Commonwealth definition)

·  Submitted a valid FBI Clearance (for staff likely to have contact with children per Commonwealth definition, and for staff who live or have lived outside of Pennsylvania within the past two years)

I am aware that under the CBH Provider Agreement, I am not permitted to employ or engage any individual who is ineligible to provide Covered Services in the Medicaid or Medicare Program or any other state or federal assistance program, as confirmed by my review of the List of Excluded Individuals and Entities (“LEIE”), the Medicheck List, and System for Award Management (“SAM”) on a monthly basis. I am able to provide proof of monthly review of all personnel in these databases upon request from CBH.

If ______becomes aware that an employee has been named in any of the aforementioned lists, ______shall issue notice of termination to the employee or Subcontractor and notify CBH (via email to ) within three (3) business days of becoming aware that an employee or Subcontractor has been excluded from participation in any state or federal program.

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