INDIVIDUAL PROVIDER APPLICATION
GENERAL INFORMATION
Last Name First Name Middle Degree/License
______
Social Security NumberTax Identification
Date of Birth:______Sex:___Male___Female
Office Location(s) (attach as needed):
Practice Name______
Street Suite
CityStateCountyZip
Handicap Accessible? Y NPublic Transportation Accessible? Y N
Telephone No.:______Ext.______
Mailing or Billing Address:
StreetSuite
CityStateCountyZip
M.D./D.O.Are you Board eligible?YN
Are you Board Certified?YN specify area______
______
Additional Information:
List languages fluent in other than English______
LIABILITY/MALPRACTICE COVERAGE INFORMATION: Please provide copy Liability Insurance Certification
Present Carrier:______
Policy No.:______Expiration Date:______
Coverage Limit:Per Occurrence:______Aggregate:______
Are there any claims pending against you?__Yes__No
Do you have any prior judgments or settlements against you?__Yes__No
Has your liability/malpractice coverage ever been denied, cancelled__Yes__No
or non-renewed?
Have you ever had your license terminated, restricted, or __Yes__No
voluntarily relinquished?
Have you ever had your permit to prescribe medication restricted,__Yes__No
suspended, or revoked?
Have you ever been suspended from practice at a hospital or other__Yes__No
health care organization?
Have you ever been subject to discipline proceedings by professional__Yes__No
organizations, licensing board, hospital staff or other such entity?
Have you ever been convicted of a felony or other crime?__Yes__No
Do you or have you ever suffered from an illness, physical or__Yes__No
psychological impairment which has interfered with your ability to
practice your specialty?
If you answered yes to any of the above, please attach an explanation.
SPECIALTY AREAS
(Please rank in order the top three areas in which you feel qualified)
____AB Abuse (Physical/Sexual)____GE Geriatric Disorders
____AD Adjustment Disorders____HV HIV/AIDS Issues
____AF Affective Disorders____MF Marital/Family
____AL Alcohol____MN Men’s Issues
____AM Adjustment to Major ____MD Medication Management
Physical Illness and Disability Only
____AN Anxiety Disorders____PD Personality Disorders
____AT Attention Deficit/Hyperactivity____PH Phobias, Panic Disorder
____BI Biofeedback/Relaxation____SD Sexual Orientation/Sexual
Training Preference Issues
____CD Chemical Dependence____WO Women’s Issues
____DD Dual Diagnosis (MI/CD)____SP Severely and Persistently
Mentally Ill
____DS Dissociative Disorders
____Other (Please specify below)
____DV Developmental Disorders
______
____ED Eating Disorders
______
Do you provide EAP Services?____Y____N
If yes, list wellness services provided:______
______
Do you provide crisis intervention services: ____Y ____N
Do you provide Psychoeducational Groups? ____Y ____N
If yes, please list:______
______
CLINICAL SERVICES (please check all that apply)
____Outpatient Group Therapy____Psychological Evaluations
Specify Type:______
______Neuropsychological Evaluations
______
______Psychiatric Evaluations
____Outpatient Individual Therapy____Outpatient Substance Abuse
Counseling
____Outpatient Family/Couples
Therapy____Case Management
____Medication Management____Inpatient Care
____Other (specify)______
______
______
______
PRACTICE POPULATIONS (check if >25% of your practice)
____Children (0-12)____Adults (18-54)
____Adolescents (13-17)____Geriatric (55+)
Please submit copies of the following with this application:
____CurrentState License(s)/certifications
____DEA Certificate (if applicable)
____ Proof of malpractice liability coverage with specified amount
(e.g. cover sheet)
I certify that the information provided in this application is correct to the best of my knowledge. I understand that any information contained in this application which subsequently is found to be false could result in denial of my application or termination from network participation.
SignatureDate