Training Acknowledgement Form

Thank you for taking Delta Dental’s Medicare training. Please submit the following information in order to complete your training.

Business Tax Identification Number (TIN)*
 
Confirm TIN*
* *
 
*
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Indicate Training Course(s) Taken*

By submitting this form, I hereby certify that all persons associated with the TIN entered above have completed the Delta Dental’s Medicare training indicated above for this calendar year.