Supervising providers, as defined in Medi-Cal policy, may use this checklist as a tool to track and document that a Medi-Cal Community Health Worker (CHW) under their supervision and for whom they intend to bill for services provided to Medi-Cal members has met the annual, continuing training requirement outlined in the Community Health Worker (CHW) Preventive Services section of the Medi-Cal Provider Manual, which is produced by the Department of Health Care Services (DHCS). When using this tool, please consider the following: 

• CHWs must complete a minimum of six (6) hours of additional training annually. 

• Training should be in core competencies, as outlined in the Medi-Cal Provider Manual, and/or specialty areas.  

• Supervising providers may provide and/or require additional training for subspecialty areas. 

• Supervising providers are ultimately responsible for maintaining documentation of the CHW(s) under their supervision completing the annual continuing education requirements.  

Note: This document is intended to be an optional tool for supervising providers and may be used to supplement documentation that an individual CHW satisfied Medi-Cal policy requirements. This document does not need to be submitted to DHCS but must be made available to DHCS upon request or in the event of a state or federal audit.   

Section A – CHW and Supervising Provider Information   

This section may be used to identify both CHW and supervising provider information.  

• CHW Name/Title:

• Supervising Provider Name/Title:

• Supervising Provider Organization:  

• Employment Start Date:  

• Type of Employment (e.g., employee, contractor, volunteer)  

Section B – Annual Continuing Training Requirement Tracker  

This section may be used to document completion of the required, annual continuous training. A table containing training topics, a brief description, hours, date completed, and supervising provider details may be used. 

Add additional pages as needed. 

Section C – Certification 

This section may be used to certify that the information provided in the checklist is accurate. 

Something such as “Check this box: I possess the requisite legal authority to submit this attestation on behalf of my organization. Further, I certify, under penalty of perjury, pursuant to applicable federal and state laws and as Medi-Cal policies, that all information provided in this attestation form is true, correct, and complete to the best of my knowledge and belief” may be included.

A list of the following may also be included:  

• Name:

• Title:  

• Email:

• Phone:  

• Signature:

• Date: