WHOLEHEALTH NETWORKS INC. PARTICIPATING PRACTITIONER AGREEMENT CERTIFICATE OF PARTICIPATIONParticipating Practitioner Agreement • February 8th, 2018
I, , (“PRACTITIONER”), hereby tender this Certificate of Participation in WholeHealth Networks, Inc (WHN) upon the terms and conditions set forth in the attached WHN Participating Practitioner Agreement and to serve as a Participating Provider for the Group benefit plans contracted on my behalf by WHN. I hereby agree to the Terms and Conditions of this Agreement. I hereby agree to extend a % (minimum of 10%) discount from my published fee schedule to all WHN Choices Program Participants (see page two for definition of Choices Program). If the above area is left blank, WHN will assume and Practitioner agrees a 20% discount will be extended to all Choices Program members.
PARTICIPATING PRACTITIONER AGREEMENTParticipating Practitioner Agreement • March 3rd, 2021
I, , (“PRACTITIONER”), hereby tender this Certificate of Participation in Healthways WholeHealth Networks, Inc (HWHN) upon the terms and conditions set forth in the attached HWHN Participating Practitioner Agreement and to serve as a Participating Provider for the Group benefit plans contracted on my behalf by HWHN. I hereby agree to the Terms and Conditions of this Agreement. I hereby agree to extend a % (minimum of 10%) discount from my published fee schedule to all HWHN Affinity Program Participants (see page two for definition of Affinity Program). If the above area is left blank, HWHN, Inc. will assume and Practitioner agrees a 20% discount will be extended to all Affinity Program members.
EMBLEMHEALTH PARTICIPATING PRACTITIONER AGREEMENTParticipating Practitioner Agreement • January 30th, 2015 • New York
Group Health Incorporated and the other EmblemHealth companies listed on the attached addendum, if any, and their affiliated and successor companies (referred to hereinafter as “EmblemHealth”), is pleased to contract with the undersigned Practitioner (“Practitioner”) for the provision of Covered Services to Members. Practitioner shall render Covered Services to Members according to the terms and conditions of this Agreement, EmblemHealth’s Administrative Guidelines, Provider Manual and policies and procedures, and each Member’s Benefit Program listed on Attachment B. Practitioner agrees to abide by the Quality Improvement, Utilization Management, Claims Submission and other applicable rules, policies and procedures of EmblemHealth. This Agreement (consisting collectively of this page, the body of the agreement that follows, the Prevailing Plan Fee Schedule and terms annexed hereto as Attachment A, plus the Addendums and Attachments which are incorporated herein and the Administrative G
PARTICIPATING PRACTITIONER AGREEMENTParticipating Practitioner Agreement • October 1st, 2012
I, , (“PRACTITIONER”), hereby tender this Certificate of Participation in Healthways WholeHealth Networks, Inc (HWHN) upon the terms and conditions set forth in the attached HWHN Participating Practitioner Agreement and to serve as a Participating Provider for the Group benefit plans contracted on my behalf by HWHN. I hereby agree to the Terms and Conditions of this Agreement. I hereby agree to extend a % (minimum of 10%) discount from my published fee schedule to all HWHN Affinity Program Participants (see page two for definition of Affinity Program). If the above area is left blank, HWHN, Inc. will assume and Practitioner agrees a 20% discount will be extended to all Affinity Program members.
WHOLEHEALTH NETWORKS INC. PARTICIPATING PRACTITIONER AGREEMENT CERTIFICATE OF PARTICIPATIONParticipating Practitioner Agreement • February 8th, 2018
I, , (“PRACTITIONER”), hereby tender this Certificate of Participation in WholeHealth Networks, Inc (WHN) upon the terms and conditions set forth in the attached WHN Participating Practitioner Agreement and to serve as a Participating Provider for the Group benefit plans contracted on my behalf by WHN. I hereby agree to the Terms and Conditions of this Agreement. I hereby agree to extend a % (minimum of 10%) discount from my published fee schedule to all WHN Choices Program Participants (see page two for definition of Choices Program). If the above area is left blank, WHN will assume and Practitioner agrees a 20% discount will be extended to all Choices Program members.
PARTICIPATING PRACTITIONER AGREEMENTParticipating Practitioner Agreement • August 29th, 2011
I, , (“PRACTITIONER”), hereby tender this Certificate of Participation in Healthways WholeHealth Networks, Inc (HWHN) upon the terms and conditions set forth in the attached HWHN Participating Practitioner Agreement and to serve as a Participating Provider for the Group benefit plans contracted on my behalf by HWHN. I hereby agree to the Terms and Conditions of this Agreement. I hereby agree to extend a % (minimum of 10%) discount from my published fee schedule to all HWHN Affinity Program Participants (see page two for definition of Affinity Program). If the above area is left blank, HWHN, Inc. will assume and Practitioner agrees a 20% discount will be extended to all Affinity Program members.
PARTICIPATING PRACTITIONER AGREEMENT CERTIFICATE OF PARTICIPATION FOR AFFINITY PROGRAMSParticipating Practitioner Agreement • March 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
