Credentialing or Recredentialing Application Alternatives
Washington State Providers ONLY- Please use the One Health Port link to complete your ProviderSource data at http://www.onehealthport.com/provider-source. You must check the “Tivity Health” Box in the Health Plan section of the attestation page to release your credentialing information to WHN.
If you are not a Washington state provider or one of the state mandated applications below please visit https://tivity.providersource.com to fill out an electronic application.
- If your credentials are in an electronic format, you may email them to Tivityapp@medversant.com(please note that sending documents via email is not a secure method) or fax them to 1.877.303.4081
- State-specific credentialing applications
- Please click on the appropriate link below.
Colorado Kentucky Louisiana Maryland Oklahoma West Virginia Nevada
- Application Options
- Tivity standard Credentialing application: Please click here for application
- Covered and Choices Practitioner Agreement: Please click here
- Attachments Required
- Completed credentialing application with signed attestation and release.
- Proof of professional liability coverage (certificate of insurance or declaration page showing limits of liability, insured’s name, and policy expiration date)
- Curriculum Vitae with education/training and employment history for the past 5 years listed in MM/YY Format.
If you have any questions, please contact us:
- Medversant Technologies, LLC.
- 330 N Brand Blvd., Suite 370
- Glendale, CA 91203
- (855) 252-4314