Current Insurance Information


 

A copy of the current pharmacy proof-of-liability insurance is required to be submitted with completed application.

 
 
 
 
 
 
 
 

I hereby represent that I have not been excluded from participation in any federal program and have not had any disciplinary action taken against me or any businesses to which I am a party. I understand that falsification of this testament shall result in rejection of this application or immediate termination of my agreement. I understand that any falsification will be reported to all local, state and federal authorities. I agree to indemnify any party who detrimentally relied on the false information provided. All information provided above, in connection with the credentialing of this facility is complete and accurate to the best of my knowledge. I understand this application does not guarantee participation in the Network. I understand a variety of sources will be used to verify the statement and documents supplied, including primary source verifications If any discrepancies are found with the information provided in this application, I understand that this facility and any other facilities under the same ownership, may be denied, terminated, or suspended from access to the Network. Furthermore, I certify that all application content and supporting documents submitted are authentic and not fraudulent, and that no information has been withheld. If any such misrepresentations and/or fraud is discovered, facility shall by liable under all applicable federal and state laws for such act, including but not limited to the Federal False Claims Act 31 U.S.C. §§ 3729 – 3733, civil tort laws in any and all jurisdictions in which the facility conducts business, and criminal penalty where applicable pursuant with the Office of Inspector General. I agree that the entity accepting this credentialing application, its’ representatives, employees, and agents shall not be liable for any act or omission related to the evaluation or verification of the information provided.

 
 
 

Please include the following documents

Accepted File Types: PDF, DOC, DOCX, JPG, JPEG