Primary Care Provider (PCP) Annual Attestation Form

Delaware First Health requires each Primary Care Provider (PCP) practice to complete an Annual Attestation Form which confirms (i) the panel size for each PCP with an assigned panel size across all payors (Medicaid, Medicare and Commercial) and (ii) the completion of a Cultural Competency Course within the past (12) twelve months. This information is requested as part of our ongoing monitoring of PCP capacity and commitment to ensuring our members receive culturally competent healthcare.

Please complete this Annual Attestation Form and upload a full Practitioner Roster. If you submitted a full Practitioner Roster within the last (6) six months and there have not been any changes, you can upload the previously submitted Practitioner Roster. The Practitioner Roster should include information for all practitioners in your practice (PCPs and specialists) at each service location.

Attestation with Roster Submission

I am submitting this PCP Attestation on behalf of the PCP practice referenced below.

Name of Individual Completing Attestation *

Professional Title *

Group Name *

Primary Practice Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Tax ID 1 *

Tax ID 2

Tax ID 3

Each practitioner on the Practitioner Roster has completed a Cultural Competency Course within the past (12) twelve months. * Yes No, but each practitioner will complete a Cultural Competency Course within the next 30 days.

Each practitioner has a PCP assigned panel/caseload across all payors (Medicaid, Medicare and Commercial) of no more than 2500 * Yes No

The roster I am submitting today * Is a complete and updated roster Is a complete and updated roster that was previously submitted within the last 6 months

Please upload roster below *

If you have any questions regarding this form, please reach out to de_providerengagement@delawarefirsthealth.com