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((j)--) <br /> HEALTHWAYS <br /> Dear Prospective Healthways Provider: <br /> Healthways is pleased to present you with the attached Healthways Provider Agreement,providing an opportunity <br /> for you to participate in the Healthways fitness provider network.Please note that the terms and conditions of the <br /> agreement, including payment, are to remain strictly confidential.Healthways' execution of your submitted <br /> agreement will be contingent on acceptance of your location into the Healthways network.Following receipt of <br /> the signed agreement,Healthways will contact you regarding your opportunity to join the provider network. <br /> Please use this fax cover sheet to fax the entire signed agreement and a copy of your location's certificate of <br /> insurance to Healthways.To confirm receipt of your agreement,please call 1-800-295-4993 ext. 5182.You may <br /> also mail the original documents to: Healthways Contracts Department, 1445 S. Spectrum Blvd., Suite 100, <br /> Chandler,AZ 85286. We look forward to receiving your agreement application. <br /> Confidential Fax Transmittal <br /> To: Fax Number: Phone Number: <br /> Healthways Contracts Department 602-391-2138 1-800-728-8492 ext.5182 <br /> From: <br /> Number of Pages(including cover sheet): <br /> Re: Application for Participation in the I-lealthways Provider Network <br /> Yes,I am interested in participating in the Healthways provider network. I am attaching the following documents <br /> for consideration: O, <br /> I gaga signed,completed contract agreement <br /> • Sign and date the agreement 2 <br /> • Complete one Exhibit A-1 for each location covered under the agreement(you may make copies of <br /> the exhibit if necessary) <br /> • Complete Exhibit A-2 <br /> I Certificate of insurance evidencing a minimum of$1M general liability insurance <br /> (Must show current policy number, expiration date,limits of liability and insured premises) <br /> U <br /> Comments: 8 <br /> E <br />