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PARTICIPATING PRACTITIONER AGREEMENT CERTIFICATE OF PARTICIPATION FOR AFFINITY PROGRAMSMarch 11th, 2014
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:❑ Copy of license(s) if applicable❑ Copy of insurance face sheet for professional and business liability policy❑ Copy of educational or training certificates, diploma, or specialty training documentation letter(s)❑ Signed release and attestation statement, with professional liability form if applicable.Please return this application along with the necessary documentation to the address listed at the top of the page to the attention of the Credentialing Department. SIGNATURE LINE I, , (“PRACTITIONER”), hereby tender this Certificate of Participation in Healthways WholeHealth Networks, Inc (“HWHN”) upon the terms and conditions set forth in this HWHN Participating Practitioner Agreement.With this Certificate, Practitioner agrees to serve as a Participating Practitioner member of HWHN for Affinity Programs, and hereby specifically au
