Doula Training Attestation

(For Doulas seeking enrollment as a New York State Medicaid Provider)

  • Attestation is also available in Word and PDF formats
This attestation form must be completed by the individual applying for enrollment in the NYS Medicaid Program as a doula provider.

I, __________________________________, hereby attest to receiving, at a minimum,
                    (print your name)

the below doula training from ________________________________________________.
                                                            (print name of doula training organization)

______________________________________________                ___________________________________
     (print address of doula training organization)                                         (phone# of doula training organization)

The minimum doula training requirements:

  • At least 24 contact hours of education that includes any combination of childbirth education, birth doula training, antepartum doula training, and postpartum doula training.
  • Attendance at a minimum of one (1) breastfeeding class.
  • Attendance at a minimum of two (2) childbirth classes.
  • Attendance at a minimum of two (2) births.
  • Submission of one (1) position paper/essay surrounding the role of doulas in the birthing process.
  • Completion of cultural competency training.
  • Completion of a doula proficiency exam.
  • Completion of HIPAA / client confidentiality training.

Date of completion of doula training: _____________________

If applicable, the date re-certification is required: ___________________

I certify that the information on this form is correct and accurate to the best of my knowledge.

Print Name

______________________________________________            ___________
Signature                                                                                                              Date

Please submit this completed attestation form and your doula training certificate* with your completed New York State Medicaid provider enrollment forms to:

Mailing Address:
Bureau of Provider Enrollment
Attention: Doula Enrollment
431 Broadway – Room A129
Albany, New York 12204

* NOTE: If the doula training organization that provided your doula training does not provide a certificate of completion, a signed and dated letter on the doula training organization’s letterhead stating you have completed a doula training course can be substituted for a certificate.

EMEDNY–433402 (11/18)