All information submitted by me on behalf of    First Name*   Last Name* an ancillary provider (the “provider”) is true and correct to the best of my knowledge and belief. I understand that as an authorized representative of the provider, I have the right to review the information submitted in support of the provider’s application. I understand that if any of this information is subsequently found to be false, misleading or incomplete, it could result in denial of the provider’s application or termination of participation in the Horizon Blue Cross
Blue Shield of New Jersey provider network, or any of its subsidiary or affiliate provider networks (hereafter collectively referred to as "Horizon BCBSNJ").
 
I understand and agree that I have the responsibility for producing adequate and accurate information for proper evaluation of the qualifications of the provider and for resolving any doubts about such qualifications. I also agree to provide information on an ongoing basis as requested and in accordance with any specific future request that is relevant to Horizon BCBSNJ's evaluation of the provider’s application, credentials or qualifications, and that this statement in its entirety shall also apply then.
 
I hereby authorize and consent to Horizon BCBSNJ's acquisition of information from any person or organization, as long as such acquisition is done in good faith and without malice in connection with Horizon BCBSNJ's evaluation of the provider’s application, credentials and qualifications.
 
I hereby release from liability Horizon BCBSNJ, its agents or designees, and any and all persons or organizations that provide information to Horizon BCBSNJ, its agents or designees, for any and all actions taken in good faith and without malice in connection with Horizon BCBSNJ's review of the provider’s application, credentials and qualifications.
 
I attest that to the best of my knowledge the information provided in response to the questions on the Re-credentialing Update Form have been answered correctly.