Common Contracts

21251 Ridgetop Circle

March 12th, 2012

• Filed
  March 12th, 2012

INSTRUCTIONS This form must be typed or printed legibly in blue or black ink. Below is a list of the items that must be submitted along with this application: List of your Group’s participating practitioners Signed credentials attestation and release statement for EACH practitioner who will be participating, with:o Copy of license(s) if applicable OR specialty certification & training documents.o Copy of insurance face sheet for professional and business liability policyPlease return this application along with the necessary documentation to the address listed at the top of the page to theattention of the Credentialing Department. SIGNATURE LINE On behalf of , ("Professional Group"), I hereby tender this Certificate of Participation in Healthways WholeHealth Networks, Inc ("HWHN") upon the terms and conditions set forth in this HWHN Participating Institutional/Group Agreement. With this Certificate, our Professional Group agrees the Practitioners herein named will serve as Participat