Medi-Cal: ACEs Provider Training Attestation

Adverse Childhood Experiences (ACEs) Provider Training Attestation

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This form is for providers to self-attest that they have completed a certified core ACEs Aware provider training. Beginning July 1, 2020, providers must attest to completing a certified core ACEs Aware provider training to continue receiving reimbursement for qualified ACEs screenings. DHCS will maintain a list of providers who have self-attested to their completion of the training and Medi-Cal Managed Care Plans will have access to the list.

Privacy Statement (Civil Code Section 1798 et seq.): The information requested on this form is required by the Department of Health Care Services for purposes of identifying providers who are eligible to receive reimbursement for qualified ACE screenings. Beginning July 1, 2020, furnishing the information requested on this form, except for the information requested under "ACEs Aware Provider Directory" is mandatory in order to continue to receive that reimbursement. Failure to provide the mandatory information may result in reimbursement being denied.

List of certified core ACEs Aware provider trainings is available here: https://www.acesaware.org/screen/provider-training/. For more information on the provider trainings and to get trained, please visit ACEs Aware or the Trauma Screenings and Trauma-Informed Care Provider Trainings page.

* Indicates required field

ACEs Provider Training Attestation

* Do you attest that you have completed a certified core Adverse Childhood Experiences (ACEs) provider training?

Yes

* Training Type

* Training Completed Date

Provider Information

These fields will be used to verify providers' identities. Only Name and National Provider Identifier (NPI) will be publicly available. Please enter your individual NPI that is used when rendering ACEs services.

* Rendering NPI

* Rendering NPI confirm

* First Name

Midle Initial

* Last Name

Business Name

* Mailing Address

* City

* State

* ZIP Code

* Phone Number

( ) -

* Email Address

* Email Address confirm

ACEs Aware Provider Directory

The ACEs Aware Initiative is developing a directory of Medi-Cal providers who have completed a certified ACEs Aware training to help Medi-Cal patients find “ACEs Aware” providers. If you choose to enroll in the ACEs Aware provider directory, the information you provide below will be shared publicly. “Service Address” refers to the location(s) where you see patients and “Business Phone Number” refers to the line patients can call to make an appointment.

If you do not consent, DHCS will not include you in the ACEs Aware Provider Directory.

Do you consent to being added to a public list of Medi-Cal providers who self-attest to completing a certified core ACEs Aware provider training?

Yes