Credentialing or Recredentialing Application Alternatives

Washington State Providers ONLY- Please use the One Health Port link to complete your ProviderSource data at 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 to fill out an electronic application.

    • Credentials
    • If your credentials are in an electronic format, you may email them to 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

    • Application Options

    • 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: