Title*
Dr. Ms. Mrs. Mr. None
First Name*

Last Name*

Individual NPI*

Attestation Statement and Authorization to Release Information

I hereby apply to become a
Primary Care
Specialist
practitioner in the Health Partners Plans network. (Please check one or both.*)

I certify that all of the information that I have submitted in connection with the application is true, accurate and complete. I understand that Health Partners Plans will rely on this information to evaluate my participation in the program(s) provided through Health Partners Plans.

I understand and agree that I am to adhere to and abide by the terms and conditions of this program(s) and any and all Agreements I have or will in the future enter into with Health Partners Plans.

I understand that any material misstatement or omission of fact on the application is grounds for action by Health Partners Plans, including but not limited to summary dismissal from Health Partners Plans as provided in the Provider Agreement.

I attest to having in the amounts required by the State of Pennsylvania current, valid malpractice insurance coverage and all other applicable professional insurances.

I agree to adhere to the code of ethics of the
Professional Organization*
AMA AOA Other Scope of Practice
If Other Scope of Practice, please specify Professional Organization
(AMA, AOA or other appropriate professional organization of specialty or scope of practice).

I authorize Health Partners Plans and/or its designated credentialing agent to consult with members of the medical staff, affiliate hospitals, professional liability carriers, and healthcare facilities with which I have been associated. In addition, this authorization includes consultation with other healthcare professionals who may have information bearing on my competency, character, physical health status, emotional health status, and ethical aspects of my professional practice.

I authorize release of such information to Health Partners Plans and/or its designated credentialing agent upon request. I agree a facsimile or photocopy of my signature will serve the same as the original.

I attest that I have clinical admitting privileges at the Health Partners Plans participating hospital noted on my CAQH or PA Standard application.

I agree to release all Medical Assistance records pertaining to sanctions and/or settlements to HPP and the Pennsylvania Department of Human Services.

I agree to attend at least one HPP sponsored provider education training session annually.

Attestation Full Name*

Attestation Date (MM/DD/YYYY)*

Attestation Confirmed (must be checked in order to submit this form)*
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