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The document is a Credentialing Application for practitioners seeking participation in the HWMG Provider Network. It outlines the responsibilities of the applicant to provide accurate information regarding their qualifications, licensure, and any disciplinary actions. The document includes authorizations for investigation and release of information related to the applicant's professional background, as well as a release from liability for HWMG and its agents. The applicant certifies the truthfulness of their application and acknowledges that any misrepresentation may lead to denial or revocation of participation.

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Click ‘Get Form’ to open the Credentialing Application in our editor.
Begin by entering your name in the designated field. Ensure that it is printed clearly as this will be used for identification purposes.
Review the sections regarding Authorization of Investigation and Release of Information. Familiarize yourself with what you are consenting to before proceeding.
In the Signature field, sign your name electronically. This confirms your agreement to the terms outlined in the application.
Finally, enter the date of signing in the provided field. This is crucial for tracking your application timeline.

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