WARNING: 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.
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.