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Adverse Childhood Experiences (ACEs) Provider Training Attestation
This is a State of California computer system that is for official use by authorized users and is subject to being monitored and/or restricted at any time. Confidential information may not be accessed or used without authorization. Unauthorized or improper use of this system may result in administrative disciplinary action and/or civil and criminal penalties. By continuing to use this system you indicate your awareness of and consent to these terms and conditions of use.
LOG OFF IMMEDIATELY
if you are not an authorized user or do not agree to the conditions stated in this warning.
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.
A list of certified core ACEs Aware provider trainings is available here:
. For more information on the provider trainings and to get trained, please visit
Trauma Screenings and Trauma-Informed Care Provider Trainings
The Date of Service is not a valid date. Please use this format: MM/DD/CCYY.
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ACEs Provider Training Attestation
Do you attest that you have completed
a certified core Adverse Childhood Experiences (ACEs) provider training?
These fields will be used to verify providers’ identities and will not be shared publicly.
National Provider Identifier
Taxpayer Identification Number
National Provider Identifier confirm
Taxpayer Identification Number confirm
Armed Forces Americas (except Canada)
Armed Forces Europe, the Middle East,and Canada
Armed Forces Pacific
District of Colombia
Federated states of Micronesia
Northern Mariana Islands
Email Address confirm
Type of Provider
Fee-For-Service Only Provider
Managed Care Only Provider
Fee-For-Service and Managed Care Provider
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?