Astiva Health : MOC Training Form
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2026 Model of Care (MOC) Training Attestation Form
  

2026 Model of Care (MOC) Training Attestation Form

2026 Model of Care (MOC)
Training Attestation Form

Astiva Health Chronic Condition Special Needs Plan (C-SNP)
This form is to be completed by all participating providers and relevant staff members upon completion of the annual Astiva Health Model of Care (MOC) training.

Provider/Medical Group/ Staff Information

Training Information

*Training Type (*):

Annual

Newly Contracted

*I am filling out this form (*):

For myself

A Group

(REQUIRED: Upload the names of all individuals who received the training in the Excel Template provided below.)

Acknowledgement and Attestation

By initialing and signing below, I acknowledge and attest to the following:
(*)
1. I have received and fully reviewed the Astiva Health Model of Care (MOC) training materials for the Special Needs Plan (C-SNP).
(*)
2. I understand the key elements of the MOC, including the description of the C-SNP population, the care coordination processes (HRA, ICP, ICT, and Transitions of Care), the specialized provider network requirements, and the quality improvement program.
(*)
3. I understand my specific roles and responsibilities as a provider partner in collaborating with the Astiva Health Interdisciplinary Care Team (ICT) to improve health outcomes for C-SNP members.
(*)
4. I agree to adhere to the principles and processes outlined in the Model of Care when providing care to Astiva Health C-SNP members.

Excel Upload

If submitting on behalf of a group, please upload names of all individuals who received training below:

  1. Download the Excel Template

    Download Excel Template

  2. Complete the Excel Template, save it to your computer, and upload the file below.


    Note: The uploaded file won't be saved until you submit the form.

Please retain a copy for your records.

2026 Model of Care (MOC)
Training Attestation Form

Astiva Health Chronic Condition Special Needs Plan (C-SNP)
This form is to be completed by all participating providers and relevant staff members upon completion of the annual Astiva Health Model of Care (MOC) training.

Provider/Medical Group/ Staff Information

Training Information

*Training Type (*):

Annual

Newly Contracted

*I am filling out this form (*):

For myself

A Group (REQUIRED: Upload the names of all individuals who received the training in the Excel Template provided below.)

Acknowledgement and Attestation

By initialing and signing below, I acknowledge and attest to the following:
(*)
1. I have received and fully reviewed the Astiva Health Model of Care (MOC) training materials for the Special Needs Plan (C-SNP).
(*)
2. I understand the key elements of the MOC, including the description of the C-SNP population, the care coordination processes (HRA, ICP, ICT, and Transitions of Care), the specialized provider network requirements, and the quality improvement program.
(*)
3. I understand my specific roles and responsibilities as a provider partner in collaborating with the Astiva Health Interdisciplinary Care Team (ICT) to improve health outcomes for C-SNP members.
(*)
4. I agree to adhere to the principles and processes outlined in the Model of Care when providing care to Astiva Health C-SNP members.

Excel Upload

If submitting on behalf of a group, please upload names of all individuals who received training below:

  1. Download the Excel Template

    Download Excel Template

  2. Complete the Excel Template, save it to your computer, and upload the file below.


    Note: The uploaded file won't be saved until you submit the form.

Please retain a copy for your records.