Evaluation Form And Acknowledgement Of Training (Page 2 of 2) in pdf

Evaluation Form And Acknowledgement Of Training Page 2

6. The IME is very interested in improving our training sessions. Please feel free to share your

thoughts, questions, and/or comments on the DVD.

__________________________________________________________________________

7. For future training sessions, please indicate any topics that you would like to have discussed.

__________________________________________________________________________

. Do you need any additional training on the topics presented today?

J Yes

J No

Please list the specific topics:

ACKNOWLEDGEMENT OF TRAINING

After reading this document in its entirety, please complete the following

Acknowledgement of Training statement and return to Iowa Medicaid

Provider Services.

Fax to: (515) 725-1155

Mail to: IME Provider Correspondence

P.O. Box 36450

Des Moines, IA 50315

Iowa Medicaid CDAC Documentation DVD Training Acknowledgement

I __________________________________ have received and viewed the

(Print Provider/Agency Name)

CDAC Documentation DVD Training.

Provider NPI ___________________________________

Phone (optional): _______________________________

Address: _______________________________________

______________________________________________

___________________________________________________________________

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Evaluation Form And Acknowledgement Of Training Page 2