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.

    • Credentials
    • 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

    • 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: