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Confidential <br />EXHIBIT A -1 <br />FACILITY INFORMATION <br />Fax: ( ) O Direct Fax O Need to call first <br />General Email: <br />Who will be our Primary location contact (Healthways Program Advisor)? This individual will be responsible for <br />scheduling training, coordinating with our Provider Services Liaison, and will need access to member records. <br />Contact Person: <br />Contact Title: <br />Contact Phone: <br />Contact Fax: ( ) <br />Contact Email: <br />