Provider Participation Attestation Sample Contracts

ATTACHMENT C
Provider Participation Attestation • January 21st, 2016

WHEREAS, Cenpatico Behavioral Health, LLC ("Cenpatico"), has executed an Agreement with ("Group") dated (date to be completed by Cenpatico) pursuant to which Group has agreed to provide Covered Services to Cenpatico Covered Persons through Group Clinicians (the "Agreement"); and

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PROVIDER PARTICIPATION ATTESTATION
Provider Participation Attestation • March 15th, 2018

WHEREAS, Group has requested that the undersigned provider ("Provider") serve as a Group Clinician under the Agreement and Provider so desires to participate; and

Sample 1
WHEREAS, Home State Health Plan, Inc ("Health Plan"), has executed an Agreement with
Provider Participation Attestation • January 9th, 2018

completed by Health Plan) pursuant to which Group has agreed to provide Covered Services to Health Plan Covered Persons through Group Clinicians (the "Agreement"); and

Sample 1
ATTACHMENT C
Provider Participation Attestation • January 21st, 2016

("Group") dated (date to be completed by Cenpatico) pursuant to which Group has agreed to provide Covered Services to Cenpatico Covered Persons through Group Clinicians (the "Agreement"); and

Sample 1
ATTACHMENT B
Provider Participation Attestation • January 21st, 2016

("Group") (insert name of contracting Group) dated (date to be completed by MHS Health Wisconsin) pursuant to which Group has agreed to provide Covered Services to Cenpatico Covered Persons through Group Clinicians (the "Agreement"); and

Sample 1
ATTACHMENT E
Provider Participation Attestation • January 21st, 2016

("Group") (insert name of contracting Group) dated (date to be completed by Cenpatico) pursuant to which Group has agreed to provide Covered Services to Cenpatico Covered Persons through Group Clinicians (the "Agreement"); and

Sample 1
ATTACHMENT C
Provider Participation Attestation • January 21st, 2016

("Group") (insert name of contracting Group) dated (date to be completed by Cenpatico) pursuant to which Group has agreed to provide Covered Services to Cenpatico Covered Persons through Group Clinicians (the "Agreement"); and

Sample 1
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