I ATTEST THAT Sample Clauses

I ATTEST THAT. There have been no changes in my physical or mental status that would impair my ability to care for a Xxxxx Vision member. ✓ I am not impaired due to chemical dependence or substance abuse. ✓ I have no history of loss of license and/or felony convictions. ✓ I have no history of loss or limitation of privileges or disciplinary activity. ✓ I will cooperate with scheduled on-site visits including reviews of record documentation and when requested, I agree to submit copies of medical records for audit purposes. ✓ I hereby affirm and attest that this application is correct and complete. ✓ Should there be any changes to the information submitted on this application, especially sections 8, 10, 11 and 12, I will notify Xxxxx Vision immediately. Submission of the completed Vision Care Provider Application and/or the Participating Provider Agreement does not constitute acceptance as a Xxxxx Vision Participating Provider. Acceptance as a Participating Provider is contingent on the acceptance by Xxxxx Vision of the Vision Care Provider Application, and on the execution by practitioner of the Participating Provider Agreement, and on the receipt by practitioner of the forms, manual and samples required for participation. Xxxxx Vision reserves the absolute right to determine which practitioner is acceptable for participation and in which groups a practitioner will participate. Following a Provider’s acceptance by Xxxxx Vision, should additional practitioner(s) join Provider’s practice and provide Covered Services to the Participant(s) of Plans under Contract with Xxxxx Vision, such additional practitioner(s) shall be subject to and bound by each and every term and condition set forth in the Participating Provider Agreement to the same extent as the original signatories to the Agreement.