wellmark, inc....s-2324 3/12 page 10 wellmark, inc. universal facility & entity application...

0S-2324 3/12

Wellmark, Inc.Universal Facility & Entity Application Addendum

To apply for participation in Wellmark networks, please complete this Addendum in combination with the Iowa Statewide Universal Facility Application. Mark N/A for the questions that are not applicable to your facility type. For specific contracting and credentialing requirements, review the Contracts and Credentialing section of the Wellmark Provider Guide, on the Provider section of Wellmark.com.

ADDITIONAL DOCUMENTATION TO INCLUDE:

• CMSApprovalLetter:hospital,hospice,skillednursingfacility,dialysiscenter,homehealthagency,ambulatorysurgerycenter,freestandingsubstanceabusefacility,ruralhealthclinic,federallyqualifiedhealthcenter,homeinfusiontherapy

• CMSSurveydocumentandcoverletterifnotnationallyaccredited:ambulatorysurgerycenter,freestandingsubstanceabusefacility/chemicaldependencytreatmentfacility,homehealthagency,hospice,hospital/specialtyhospital,skillednursingfacility

SECTION M. GENERAL INFORMATION

SchedulingPhoneNumber ________________________ TDDPhoneNumber(hearingimpaired) __________________

Administrator’sName ___________________________ Administrator’s email address _________________________

CredentialingContactName _______________________ Credentialingemailaddress ___________________________

CredentialingAddress _______________________________________________________________________________

CredentialingCity,State,Zip __________________________________________________________________________

CredentialingPhonenumber __________________________________________________________________________

Whatlanguagesarespokenatthisaddress? ______________________________________________________________DoyoubillelectronicallytoWellmarkforfacilityservices? Yes NoDoyoubillelectronicallytoWellmarkforprofessionalservices? Yes NoDoyoustoreelectronicmedicalrecords? Yes NoDoesyourlocationhavepublictransportationaccess? Yes NoDoyouhavetheabilitytosubmitclaimstoCMS? Yes No

Doesyourorganizationownorhaveownershipinterestinahealthcarefacilityororganizationwithwhichyouareaffiliated?(independentlab,nursinghome,retailpharmacy,freestandingradiology/imagingcenter,rehab,freestandingsleepcenter,durablemedicalequipmentsupplier)? Yes No

Ifyes,pleaseprovidenameoffacility,address,percentofownership,ownedby,nameoforganization. ___________________

________________________________________________________________________________________________

________________________________________________________________________________________________

Inwhatnetworksdoesyourfacilityorentitywishtoparticipate?ClassicBlueAllianceSelectSelectFirstTRICAREBlueAccessBlueChoiceBlueAdvantageMedicareAdvantage

SECTION N. EFFECTIVE DATE

WhatistheeffectivedatetoperformservicesforWellmarkmembers? ___________________________________________

Radiology Center Services/CapacityPlease check the services that are available at your hospital/facility. These may or may not be a covered benefit.

BoneScan NuclearMedicine

CTScan PETScan

DEXAScan PET/CT

Echocardiography PET/CTA

Mammography RadiationTherapy

MRA UltraSound

MRI

S-2324 3/12 Page 11

SECTION R. DURABLE MEDICAL EQUIPMENT SUPPLIER

•PleaseprovideaccreditationinformationinSectionEofthisapplication.•Ifyouprovideorthoticsandprosthetics,seeSectionWbelow.

IfyoudonothavetheabilitytobillCMS,pleaseexplain: _____________________________________________________

SECTION P. PROFESSIONAL LIABILITY INSURANCE

WellmarkneedsliabilityinformationtocoveryoureffectivedateandalsowhenyouarecredentialedbyWellmark.IftheliabilityinformationinSectionEofthisapplicationdoesn’tcoverbothofthosedates,pleaseprovideadditionalcoverageinformation.

CarrierName ____________________________________ City/State ____________________________________

PolicyNumber ___________________________________

$ Amounts Per Occurrence __________________________ $ Amounts Aggregate ____________________________

Datefrom(mm/dd/yyyy)______/______/______ Dateto(mm/dd/yyyy)______/______/______

SECTION Q. AMBULANCE SERVICE

Doesyourambulanceserviceoperateondonations? Yes No

Doesyourambulanceservicechargeaflatfeeforservices? Yes No

Isyourambulanceservicehospitalbased? Yes No

Ifyes,pleaseprovidethenameofthehospitalandlocation.

Nameofhospital: __________________________________________________________________________________

City,State: _______________________________________________________________________________________

SECTION O. PROVIDER IDENTIFICATION NUMBERS

Doyoucurrentlyhaveastatecertificationnumber? Yes NoIfyes,pleaselist: ____________________________EnteryourNationalProviderIdentifier(NPI)number.

Acutehospital ____________________Ambulance ______________________AmbulatorySurgeryCenter __________CMHC _________________________Dialysis ________________________DME ___________________________FQHC __________________________Freestanding Radiology ____________

HomeHealthAgency ______________HomeInfusionTherapy ____________Hospice ________________________IndependentLab __________________Orthotic/Prosthetic ________________PMIC __________________________Psychiatric ______________________PublicHealthAgency ______________

Rehab __________________________RuralHealthClinic ________________SkilledNursing ___________________SleepCenter _____________________Swing-bed ______________________VisitingNurseAssociation ___________Other: _________________________

Ifyouhavemultiplefacilities,pleaselisteachnameinSectionEE.

S-2324 3/12 Page 12

SECTION R. DURABLE MEDICAL EQUIPMENT SUPPLIER (cont.)

Check supplies provided

AirMattress(tech) AugmentativeDevice(tech) Back-UpEquipment(tech)

BathChair(medsupp) Bi-Pap(resp)(tech) BreastPumps(medsubb)

ChestCompressionApparatusfor CysticFibrosis(resp)

CPMMachine(tech) Commodes(medsupp)

ComputerSoftware(tech) DiabeticShoes/Inserts(tech) DiabeticSupplies(medsupp)

EasyStander(tech) EmergencyMaintenance(tech) Enteral(medsupp)

EZLockWheelchair(mobile) FeedingPumps(tech) GrabBars(tech)

HandControlforVehicle(mobile) HearingAids(other) HomeCare(other)

HospitalBeds(tech) InfusionPumps(tech) InfusionTherapy-Adult(medsupp)

InfusionTherapyPediatric(medsupp) JazzyWheelchair(mobile) MechanicalVentilators(resp)

MedicalEquipmentRepairs/Service(tech) MedicalSupplies(medsupp) Ostomysupplies(medsupp)

Parenteral(medsupp) PediatricVents(resp) PulseOximeter(tech)

Respiratory(resp) RespiteCare(other) RestrainSystem(medsupp)

RT-300ErgometerCycle(tech) SpecializedBeds(tech) TPN(medsupp)

Urinary supplies VanLift(mobile) Walker(medsupp)

SpecialWheelchair-custom(mobile) SpecialWheelchair-Manual(mobile)

WheelchairLiftCar(mobile)

WoundCaresupplies

SECTION S. FREESTANDING SUBSTANCE ABUSE CENTERS/CHEMICAL DEPENDENCY TREATMENT FACILITIES

•PleaseprovideacopyofthecompleteStateInspectionReport

•PleaseprovideaccreditationinformationinSectionEoftheapplication

•TRICARErequirescertificationbyKePro(www.kepro.com)

Isyourfacilityequippedtoprovideacuteinpatientmanagement24hoursaday? Yes No

Howmanybedsdoyouhaveavailableforacutetreatment? ___________________________________________________

SECTION T. HOSPITAL/SPECIALIZED HOSPITAL

•Pleaseprovideaccreditation/certificationinformationinSectionEoftheapplication.•TRICARErequiresfreestandingmentalhealthinstitutionsandpartialhospitalizationprogramstobecertifiedbyKePro(www.

kepro.com)

TraumaLevel:Level1Level2Level3Level4Level5Notapplicable

DoyouparticipatewiththeNationalDisasterMedicalServices(NDMS)? Yes No

Check services provided

AcuteCare Alcohol/ChemicalDependency- AdolescentDetox

Alcohol/ChemicalDependency- Adolescent OP

Alcohol/ChemicalDependency- AdolescentPartialHospitalization

Alcohol/ChemicalDependency- AdolescentRehabilitation

Alcohol/ChemicalDependency-AdultDetox

Alcohol/ChemicalDependency-AdultOP

Alcohol/ChemicalDependency-AdultPartialHospitalization

Alcohol/ChemicalDependency-AdultRehabilitation

Ambulance-Air Ambulance-Hospital-based Audiology

S-2324 3/12 Page13

Check services provided

BehavioralHealth BirthingRooms BloodBank

BurnUnit Cancer Cardiac

CardiacRehabilitation CochlearImplantSurgery CTScan

DiabetesEducation Dialysis-OP EEG monitoring

Emergency Room GammaKnife GeriatricServices

HomeHealthServices(notseparatelyMedicarecertified)

HomeInfusionTherapy(not separatelyMedicareCertified

HospiceCare

HyperbaricTreatment ICU-IntensiveCareUnit IOP-IntensiveOtptProgram

Lab-OP LabServices Lithotrispy

Mammography Maternity MRA

MRI NeonatalICULevel1 NeonatalICULevel2

NeonatalICULevel3 NeurologyServices NuclearMedicine

Nursery Obstetrics OccupationalTherapy-IP

OccupationalTherapy-OP OccupationalTherapy-IP/OP Oncology

OpenHeartSurgery OrthopedicServices OutpatientSurgery

PainManagement PartialHospitalization PediatricHematology/Oncology

PediatricICU PediatricEmergencyCare PediatricPhysicalTherapy

PediatricRehabilitation Pediatrics PETScan

PhysicalTherapy-IP PhysicalTherapy-OP PhysicalTherapy-IP/OP

PsychiatricServices-AdolescentEating Disorder PsychiatricServices-AdolescentIP PsychiatricServicesAdolescent

Outpatient

PsychiatricServices-AdolescentPartialHospitalization

PsychiatricServices-AdultEatingDisorder PsychiatricServices-AdultIP

PsychiatricServices-AdultOP PsychiatricServices-AdultPartialHospitalization PsychiatricServicesChildIP

PsychUnit(notseparatelyMedicarecertified) RadiationCenter Radiation Oncology

RehabUnit(notseparatelyMedicare certified) ResidentialCare SleepStudies

SNFUnit(notseparatelyMedicarecertified) SpeechTherapy-IP SpeechTherapy-OP

SpeechTherapyIP/OP SportsMedicine SwingBed(notseparatelyMedicarecertified)

Transplant-BoneMarrow Transplant-Cornea Transplant-Heart

Transplant-Heart/Lung Transplant-Kidney Transplant-Liver

Transplant-Liver/Kidney Transplant-Pancreas/Kidney Transplant-SmallIntestine

Transplant-SmallIntestine/Liver Transplant-Tissue TraumaticBrainInjury

UltraSound UrgentCare VentilatorCare

SECTION T. HOSPITAL/SPECIALIZED HOSPITAL (cont.)

S-2324 3/12 Page14

SECTION V. ORTHOTICS/PROSTHETICS

SECTION W. PUBLIC HEALTH AGENCY/VISITING NURSE ASSOCIATION

• PublicHealthAgency:PleaseprovidedocumentationfromtheBoardofSupervisorsorBoardofHealthdesignatingyouragencyasthepublichealthagencyforyourcounty/area

• VisitingNurseAssociation:PleaseprovidedocumentationfromCMSindicatingyourabilitytobillforimmunizationsgiventoMedicarebeneficiaries

AsaPublicHealthAgency,whichcountieshaveyoubeendesignatedasthepublichealthagency? _____________________

________________________________________________________________________________________________

AsaVisitingNurseAssociation,areyouamemberoftheVisitingNurseAssociationofAmerica? Yes No

AsaVisitingNurseAssociation,areyoucertifiedbyCMStobillimmunization? Yes No

• PleaseprovideAccreditationinformationinSectionEofthisapplication.Ifyouonlyprovidemastectomyfitting,youmusthaveanABCorBOCcertifiedfitteronstaff.Pleaseprovidethefitter’snameandcertificationinformationincludingcertificationdates.

______________________________________________________________________/______/______Name Certification CertificationDate(mm/dd/yyyy)

Whatservicesdoyouprovide(markallthatapply)?Orthotics Prosthetics Mastectomy Ocularist

SECTION U. INDEPENDENT LABORATORY

WhatlevelofCLIAcertificationdoesthelabhave? Accreditation Waiver Compliance Registration

Provider-PerformedMicroscopyProcedures

NameofthefacilityontheCLIAcertificate _______________________________________________________________

SECTION X. PSYCHIATRIC MEDICAL INSTITUTIONS for CHILDREN

•PleaseprovideaccreditationinformationinSectionEofthisapplicationHowmanybedsdoyouhaveavailablefortreatment?_____________________

Howmanyhoursperdayofonsitenursingareavailable?Lessthan8hours8ormorehours

IsaRNavailable24hoursaday,7daysaweek? Yes No

Doyouhaveoneormorefulltimestaffpsychiatrists? Yes No

Ifyes,pleaseprovidethenameandstatelicenseinformationbelow.

______________________________________ ___________________ __________ ______/______/______Name LicenseNumber State EffectiveDate(mm/dd/yyyy)



Check services/supplies provided

Back-UpEquipment CustomFabricatedOrthotics CustomFitOrthotics

DiabeticShoes/Inserts EmergencyMaintenance LimbProsthetics

MedicalEquipmentRepairs/Service OfftheShelfOrthotics OrbitalProsthesis

Orthotics Prosthetics ProstheticDevices

Respiratory

S-2324 3/12 Page15

Imaging Equipment Used at this SitePleaselisteachpieceofequipmentusedtoprovideservices.IndicateTypeofServiceinthe“Type”column-CT,CTA,NuclearCardiology,PET,PET/CT,MRI,MRA,Echocardiography,Other(specify).Completeallinformationrelatedtothatpieceofequipment.

Type Manufacturer Model Year

SECTION Y. RADIOLOGY/IMAGING CENTER

TypeofServices CheckifServiceisOffered

AccreditedBy (OrganizationName(s))

Date Accredited Accreditation Renewal Date

CT // //

CTA // //

NuclearCardiology // //

PET // //

PET/CT // //

Mammography // //

MRI // //

MRA // //

Echocardiography // //

Other(specify) // //




•PleaseprovideaccreditationinformationinSectionEofthisapplication

SECTION Z. RURAL HEALTH CLINICS / FEDERALLY QUALIFIED HEALTH CENTERS

•RuralHealthClinics:PleaseprovideacopyoftheInterimRateLetter.FacilityType: RHC FQHC–rural FQHC-urban

ListtheIowacountieswhereyouprovideservices. __________________________________________________________

ListtheSouth Dakotacountieswhereyouprovideservices. ___________________________________________________

Providetherequestedinformationregardingallofthephysiciansand/orpractitionersatyourclinicinthetablebelow.

S-2324 3/12 Page 16

SECTION AA. SLEEP CENTERS – FREESTANDING OR HOSPITAL-BASED

•Tobelistedintheproviderdirectory,yoursleepcentermustbecontractedandcredentialed.•PleaseprovideaccreditationinformationinSectionEofthisapplication.

Howmanybedsdoyouhaveavailableforsleepstudies? ____________________________________________________DoyouhaveamedicaldirectororstaffphysicianwhoisBoardCertifiedinSleepMedicine? Yes NoIfyes,pleaseprovidethename(s)below.

____________________________________________ _____________________ ______/______/______Name Board ExpirationDate(mm/dd/yyyy)



Isyourmedicaldirectororstaffphysicianavailabletoprovideface-to-facereviewofstudyresultstosleepcenterpatients? Yes No

SECTION BB. SKILLED NURSING FACILITY

•Pleaseprovideaccreditation,certificationandlicensureinformationinSectionEofthisapplication.

Physician/PractitionerName,degree/title(List every physician or practitioner providing care at the RHC or

FQHC)

NPI(if applicable)

Willthisphysicianorpractitionerbillforservicesoutsideofthe

encounterrate?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Mark services provided

BehavioralHealthDualDiagnosis CardiacDrips CardiacRehabilitation

HemoDialysis HyperbaricTreatment Inpatient

IV Administration LevelsofCare NeurologyServices

OccupationalTherapy-IP OccupationalTherapy-IP/OP OccupationalTherapy-OP

OrthopedicServices OstomyCare OxygenTherapy

Pediatrics Pediatric Vents PostHospitalization

Post Transplant PhysicalTherapy-IP PhysicalTherapy-IP/OP

PhysicalTherapy-OP ResidentialCare Specialized/ComplexWoundCare

SpecialtyBeds(types) SpeechTherapy-IP SpeechTherapyIP/OP

SpeechTherapy-OP SuctionTherapy Trachs

Transportation TraumaticBrainInjury Vents

WoundCare Wound Vac

SECTION Z. RURAL HEALTH CLINICS / FEDERALLY QUALIFIED HEALTH CENTERS (cont.)

S-2324 3/12 Page17

SECTION CC. HOME INFUSION THERAPY PROVIDERS

•PleaseprovideaccreditationinformationinSectionEofthisapplication.

Whattypeofpharmacylicensedoyouhold? General HospitalNon-Resident

Yes NoDoesthislocationmeettheStatesterilecompoundingrequirements?

Yes NoIsthislocationrecognizedbyCMSasaDMEsupplierandapharmacy?

Yes NoDoestheMedicalDirectorhaveexpertiseininfusiontherapyservicestoprovideoveralldirectionfortheclinical apsectofthehomeinfustiontherapy?

Yes NoDoesthislocationhaveamedicaldirectororRNthatdevelops,coordinatesandsupervisesallactivitiesofnursing services,includingresponsibilityforassuringthatonlyqualifiedindividualsadministerhomeinfusiondrugs?

Yes NoAreRNsprovidingdirectpatientcare?

Yes NoDoyousubcontactforthenursingservices?

Ifyes,pleaseprovidethenameoftheagencyusedforsubcontractedservices: _________________________

____________________________________________________________________________________

Yes NoDoyoudeliverinfusionserviceswithin24hoursofreceiptofphysician’sorder?

Yes NoDoyouhaveasystemensuringpromptdeliveryandappropriatestorageofpharmaceuticals,suppliesand maintenanceandserviceofequipment?

Yes NoDoyouprovideamedicalwastedisposalsystemforin-homeuse?

Yes NoDoyouhaveadocumentedrecallpolicyandprocedureintheeventofanFDArecallonaninfusionproduct?

Yes NoDoyouprovidecareundergeneralsupervisionofpatient’sphysician?

Yes NoIstheplanofcarereviewedatleastevery30daysorasoftenasthepatient’sphysiciandeemsnecessary?

S-2324 3/12 Page18

SECTION DD. CORPORATE CONTRACTS LIST OF LOCATIONS - To be used by Corporate Providers

Listoflocations–includeanylocationsinIowa,SouthDakotaorcountiesborderingeitherstatePleasecompletetheinformationbelowforeachlocationorifyouhaveaspreadsheetthatwouldincludeallofthisinformation,pleaseattachittothisapplication.Ifadditionalspaceisneeded,pleasecopythispage.Wellmarkwilldetermineeligibilityfornetworksaccordingtoourrequirementsandeachspecificlocation.

CheckiftheAPPLICATIONCONTACT(SectionB)isthesameforallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.

CheckiftheBILLINGINFORMATION(SectionC)isthesameforallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.

CheckhereiftheMEDICALDIRECTOR(SectionD)isthesameforallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.

CheckhereiftheACCREDITATION/CERTIFICATION/LICENSUREINFORMATION(SectionE)appliestoallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.

CheckhereiftheLIABILITYINFORMATION(SectionsF&Q)appliestoallyourlocations.Ifnot,pleaseprovidethisinformationperlocationinSectionFF.

NPI: _______________________________________ TIN(if different at this site): ______________________________

StateCertificationNumber: _____________________ Whichstate(s)? _______________________________________

Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________

SchedulingPhoneNumber: ______________________ TDDPhonenumber(hearing impaired): _____________________

EffectiveDatetoSeeWellmarkmembers: _________________________________________________________________

Languagesspokenatsite: _____________________________________________________________________________

_________________________________________________________________________________________________

____________________________________________________________________________________________________



Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________




_________________________________________________________________________________________________

____________________________________________________________________________________________________



Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________




_________________________________________________________________________________________________

S-2324 3/12 Page 19



Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________




_________________________________________________________________________________________________

____________________________________________________________________________________________________



Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________




_________________________________________________________________________________________________

____________________________________________________________________________________________________



Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________




____________________________________________________________________________________________________

____________________________________________________________________________________________________



Name: ___________________________________________________________________________________________

Street: ___________________________________________________________________________________________

City,State,Zip: _____________________________________________________________________________________




_________________________________________________________________________________________________

____________________________________________________________________________________________________

SECTION DD. CORPORATE CONTRACTS LIST OF LOCATIONS - To be used by Corporate Providers (cont.)

S-2324 3/12 Page 20

For all Wellmark networks, you must sign and date this section. Please do not back date it. It will be returned if signature date is older than 60 days.

Confirmation of Provider EnrollmentForanelectronicsummaryoftheprovider’snetworkparticipationstatusresultingfromthisapplication,completethefollowingfields.Ifyouwouldlikeotherstoreceivethisinformation,suchasbillingstaff,includee-mailaddressesonthelinesprovided.

PrimaryContact ____________________________________________________________________________

PrimaryContactPhoneNumber _________________________________________________________________

PrimaryContactE-mailAddress _________________________________________________________________

OtherE-mailAddress(es) ______________________________________________________________________

Note:ifacontractisbeingsignedaspartoftheapplicationprocess,thisoptionisnotavailable.Contract(s)andparticipationstatuswillbesentbymail.

Certification and ReleaseIunderstandthatanyinformationenteredonthisapplicationandanyWellmark,Inc.addendaappropriatetomyspecialtywhichsubsequentlyisfoundtobefalsecouldresultinimmediatedismissalfromanyWellmarkprogram.

IherebycertifythattheinformationcontainedinmycompletedWellmarkapplicationisaccurate,trueandcomplete.IauthorizereleaseofinformationasmayberequiredbyWellmarktoprocessthisapplicationandunderstandandagreeWellmarkmaycommunicatewithmethroughvariousmeans,includingbutnotlimitedtotelephone,mail,and/oremailovertheinternetregardingthisapplication.MysignatureonmycompleteapplicationdoesnotconstituteacontractwithWellmark.BysigningthisapplicationwhichrepresentsalladdendabyWellmark,IauthorizeWellmarktoreleasethisinformationtoWellmarksubsidiariesandaffiliates.

AuthorizedSignature_____________________________________________________________/_______/_______ Date (mm/dd/yyyy)

AuthorizedPerson’sNameandTitle(pleasetypeorprint) ____________________________________________________

Certification and Release of the individual preparing the application. Complete this section if this application has been prepared by someone other than the authorized person indicated above - include name and title

I,___________________________________,herebyattestthattheinformationincludedonthisapplicationisaccurate,true,andcompleteandcanberetrievedfromthefileslocatedat

______________________________________________ __________________________ __________________FacilityName StreetAddress City

_________________________________________________ _______/_______/_______Preparer’sSignatureandTitle Date(mm/dd/yyyy)

SECTION EE. CERTIFICATION AND RELEASE

Applicantshavethefollowingrights:•Youmayrequesttoreviewtheinformationsubmittedinsupportofyourcredentialingapplication.•Youmaycorrectanyerroneousinformationfoundinyourcredentialingfile.•Youwillbenotifiedofanyinformationcollectedduringthecredentialingprocessvariessubstantiallyfromtheinformationyousubmitted.

S-2324 3/12 Page 21

SECTION FF. ADDITIONAL INFORMATION:

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

__________________________________________________________________________________________________

wellmark, inc....s-2324 3/12 page 10 wellmark, inc. universal facility & entity application...

Documents