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1. Provider
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2. Referral
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3. Practice
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4. Education
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5. License/Certification
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6. Insurance
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7. Work History
8. EAP Counselor
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9. Disability Provider
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10. FFD Specialist
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11. Provider Profile
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12. Attestation
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13. W-9
5. LICENSE/CERTIFICATION INFORMATION
A. PROFESSIONAL LICENSE(S):
Please identify in the list below,
all
health care licenses held in the past ten- (10) years. Indicate original licensure date through current expiration date for each state in which you are or have been licensed/certified. Please provide an explanation for any license that is no longer current, whether by voluntary relinquishment or disciplinary or other action. If you are unable to upload this document, please fax to 866-612-7795.
Edit
Type
Certifying Entity
State
Issued
Delete
No Records Found
For each license/certification you hold, you will need to click the Add License/Certification button to input your information.
How many years do you have of post-license clinical experience in the direct provision of mental health/substance abuse care?
Years of managed care experience?
B. BOARD CERTIFICATION SPECIALTY:
List below any certifications you have received from any nationally recognized specialty boards.
PRINCIPAL SPECIALTY
Name of Board (if board certified)
Exam Information (check one):
Oral exam taken
Oral exam scheduled
Written exam taken
Written exam scheduled
No plans to take exam
Exam Date:
Date Certified:
Re-exam Date:
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
SECONDARY SPECIALTY
Name of Board (if board certified)
Exam Information (check one):
Oral exam taken
Oral exam scheduled
Written exam taken
Written exam scheduled
No plans to take exam
Exam Date:
Date Certified:
Re-exam Date:
(MM/DD/YYYY)
(MM/DD/YYYY)
(MM/DD/YYYY)
C. ADDITIONAL CERTIFICATIONS:
List below any certifications you have received from any nationally recognized specialty boards.
Certification Type
Certificate #
Expiration Date
American Nursing Credentialing Center (ANCC) Board Certification (i.e. APRN, BC)
(MM/DD/YYYY)
Certified Employee Assistance Professional (CEAP)
(MM/DD/YYYY)
Chemical Dependency Certification (Specify):
(MM/DD/YYYY)
Please include a current copy of your certification with your application materials.
If you are unable to upload this document, please fax to 866-612-7795.
D. ADVANCED PRACTICE NURSE (APN only)
Yes
No
Are you currently recognized by your state licensing board to practice as an Advanced Practice Nurse?
Do you hold prescriptive authority in the state(s) in which you are licensed to practice?
Are you required by your licensing board to hold a collaboration agreement with a physician?
Does your licensing board require you to be supervised by a physician?
If you are required to collaborate or be supervised by a physician, is the physician a psychiatrist?
Do you have a Federal DEA certificate?
Do you hold a state issued Controlled Dangerous Substance (CDS) Registration or Rx #?
This section to be completed by APN's who are required to collaborate or be supervised by a physician.
Name of collaborating/supervising physician:
Specialty of collaborating/supervising physician:
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