ValueOptions Provider Data Sheet

12. ATTESTATION/PARTICIPATION STATEMENT

For purposes of making this application for participation in the ValueOptions, Inc. provider network, I certify that all information provided to ValueOptions is true and correct to the best of my knowledge and belief. I agree to notify ValueOptions promptly if there are any material changes in the information provided, whether prior to or after my acceptance as a ValueOptions participating provider. I understand and agree that if ValueOptions discovers that my application contains any significant misstatement, misrepresentations, or omissions, ValueOptions may void, in its sole discretion, this application and any related participating provider agreements.

I authorize ValueOptions and its Credentialing Verification Organization (CVO) to consult with the National Practitioner Data Bank, and associated Data Banks, State Licensing board(s), educational institutions, specialty boards, malpractice insurance carriers, Education Commission for Foreign Medical Graduates, hospitals, professional references and any other person or entity from whom/which information may be needed to complete the credentialing process or to obtain and verify information concerning my membership, professional competence, character, moral and ethical qualifications. I also authorize all of them to release such information to ValueOptions. I release ValueOptions and its CVO and employees and agents and all those whom ValueOptions and its contacts from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluation my application.

I understand that ValueOptions may be required by the Federal government or its clients to perform a criminal records check as a condition for participation and that ValueOptions has the right to obtain a copy of a criminal history report and share such record with the account for which member are treated I also understand that I have the right to challenge the accuracy and completeness of any information contained in such a report.

I consent to the release by any person to ValueOptions and its CVO, all information that may reasonably be relevant to an evaluation of my professional competency, character and moral and ethical qualifications, including information relating to any disciplinary action or suspension or curtailment of privileges, and hereby release any such person providing such information from any and all liability for doing so.

I further understand and agree that: (a) I am responsible for producing all information required or requested by ValueOptions in connection with this application; (b) ValueOptions shall not complete the processing of this application until such information is provided by me. In the event that ValueOptions decides not to accept me as a participating provider and I desire to have the decision reviewed, I will appeal such determination to the ValueOptions Provider Appeals Committee (“PAC”). By signing this Attestation/Participation Statement I am not precluded from pursuit of any separate rights that I may have under state or federal laws.

	Date: (MM/DD/YYYY)
Signature of Applicant


Name of Applicant	Social Security Number

FAX SIGNED ATTESTATION WITHIN 5 DAYS TO:
ValueOptions, Inc.
National Network Operations
FAX: (866)-612-7795
If you have any questions regarding the application, please call 1-800-397-1630

ValueOptions, Inc is an equal opportunity organization, which does not discriminate on the basis of race, color, sex, national origin, religion, age, disability, or veteran status in admission or access to or treatment or employment in its programs and activities. Applicants who may have inquiries regarding our policy and procedures should contact the National Network Development and Management Department.