Non-PCP Annual Attestation Form

Delaware First Health asks that each Provider Practice complete an Annual Attestation Form confirming the completion of a Cultural Competency Course within the past twelve (12) months. Cultural competency is essential to delivering high-quality care. It helps providers understand and respect the diverse backgrounds, beliefs, and needs of patients—leading to better communication, improved health outcomes, and stronger patient trust.

NOTE: Primary Care Physicians (PCPs) should use a different form, Primary Care Provider (PCP) Attestation Form which confirms annual completion of cultural competency coursework and PCP panel size across all payors.

Cultural Competency Attestation

I am submitting this attestation on behalf of the provider 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

Have all practitioners in your practice completed a Cultural Competency Course within the past twelve (12) months? * Yes No, but each practitioner will complete a Cultural Competency Course within the next 30 days.

If you have any questions regarding this form or need assistance, please reach out to: deprovidercommunications@delawarefirsthealth.com.