Uniform Application To Participate as a Health Care Practitioner

Transcription

1 Sandhills Center (SHC) for MH, DD & SAS Uniform Application To Participate as a Health Care Practitioner (Licensed Independent Practitioner - LIP) Please submit application to: Credentialing and Contracting Specialist Network Operations Dept. Sandhills Center P.O. Box 9 West End, NC Uniform Application to Participate Page 1 of

2 INSTRUCTIONS A prospective Licensed Independent Practitioner must apply for and be credentialed as a practitioner with SHC to qualify for reimbursement of services provided to SHC consumers. Additionally, Practitioners must have a signed contract with SHC or be employed by an Organization or Group Practice that has a signed contract with SHC to qualify for reimbursement of services provided to SHC consumers. The credentialing process includes the following steps: 1. Provider completes and signs the Uniform Application to Participate and returns it along with the required credentials to: Sandhills Center for MH/DD/SAS Network Operations Department Attn: Credentialing and Contracting Specialist PO Box 9 West End, NC A Uniform Application to Participate is considered to be invalid and must be returned to the provider for correction and/or for additional information if: The version date on any of the documents that comprise the provider enrollment packet is prior to February All spaces in the application have been completed. (Please indicate N/A or None, if the question is not applicable) The Signatures, where required, are not original. The Signatures are not by the individual applicant. The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids. The responses are illegible. The National Provider Identifier is not a valid number. Any of the documents or pages that comprise the Uniform Application to participate as a Health Care Practitioner are missing. Any of the requested information in any of the documents that comprise the Uniform Application to participate is missing, with the exception of the fax number and address. Before submitting the Application, make sure you have completed the following: Include an answer in all spaces. Indicate N/A or None, if the question is not applicable. The practitioner for whom the Application is being submitted has signed and dated the last page of the Application. Before submitting the Application, make sure you have enclosed the following, if applicable: Copy of the provider s original state(s) license(s) and current registration. If provisionally licensed, submit a current copy of your supervision contract and complete the clinical supervisor information on page 7 of this application. Copy of current Federal DEA certificate (for MDs, Physician Assistants and Psychiatric Nurse Practitioners). The Certificate must have a valid date and refer to current address. Copy of South Carolina Controlled Drug Substance Certificate and DEA information, if applicable. Copy of the face sheet of your current professional liability insurance policy, indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, and policy number. Attach previous carrier face sheet. Proof of professional liability insurance for non-physician providers who care for patients in your practice. Coverage amounts $1,000,000 / $3,000,000. Uniform Application to Participate Page 2 of

3 Copy of National Provider Identifier (NPI) Certification Letter for Agency and Clinician(s). Copy of certificate from the Specialty Board, if applicable. Copy of Educational Commission of Foreign Medical Graduate Certificate-ECFMG, if applicable Letter(s) of reference or recommendation, and/or oversight, if required. (SHC Provider Evaluation Forms included in this packet). Minimum of two (2) references. Must be dated within the past 180 days. At least one of the references needs to come from a like-licensed practitioner. SHC reserves the right to contact at least one (1) reference. NOTE: If provisionally licensed, one of the references must come from your clinical supervisor Copy of Curriculum Vitae or work history after graduation from Medical, Dental or other professional school. NOTE: CV must account for any gaps of one hundred eighty (180) days or more. Copy of W-9 Form. Copy of original transcripts from the college/university for the highest degree obtained unless SHC has verified the designated licensure board performs Primary Source Verification. Examples of documentation to attach to this application: Original N.C. License DEA Registration Medical Board Registration Board Certification Certificate of Insurance Uniform Application to Participate Page 3 of

4 APPLICATION ACKNOWLEDGEMENT CARD Please fill in the information below. This is our method of acknowledging receipt of your application. PLACE A STAMP ON THE ACKNOWLEDGEMENT CARD TO ENSURE DELIVERY BY THE POST OFFICE. Sandhills Center Network Operations Department Credentialing Specialist PO Box 9 West End, NC PLACE STAMP HERE. POST OFFICE WILL NOT DELIVER WITHOUT PROPER POSTAGE. APPLICATION ACKNOWLEDGEMENT CARD Dear Prospective Provider: We have received your application for enrollment in the Sandhills Center Provider Network. SHC will notify you by phone once your application has been processed to facilitate a contract, set you up as an out-of network provider, or in the event additional information is needed. Thank you again for your interest in the Sandhills Center Health Plan (SHCHP) Medicaid Program. Sincerely, Network Operations Department

5 A. DEMOGRAPHIC AND PERSONAL DATA: 1. Name of Applicant: Last Name First Name Middle Name Maiden 2. Date of Birth: / / Place of Birth: Social Security Number: - - Sex: Male Female 3. Type of Practice: Primary Care Specialist Please Identify Areas of Clinical Expertise and treatment by completing and signing the Practice Preference Data on the attached Cultural, Racial, Ethnic, Gender, and Linguistic Data Form. What population(s) do you treat (e.g., geriatric, all ages)?: Language(s) Spoken, including sign language: Are interpreters available? 4. Name of Practice: 5. Primary Office Address (If you maintain more than one office, list each office, address, and hours of operation.) Practice Name Street City County State Zip Office Phone: ( ) - / Fax ( ) - / Accepting New Patients? YES NO Restrictions: Handicapped accessible? YES NO If no, explain how you would accommodate a handicapped consumer: Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday Secondary Office Address Practice Name Street City County State Zip Office Phone: ( ) - / Fax ( ) - / Accepting New Patients? YES NO Restrictions: Handicapped accessible? YES NO If no, explain how you would accommodate a handicapped consumer: Uniform Application to Participate Page 5 of

6 A. DEMOGRAPHIC AND PERSONAL DATA (Continued) Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday Additional Office Address or Billing Address, if different (check one) Billing Office Practice Name Street City County State Zip Office Phone: ( ) - / Fax ( ) - / Accepting New Patients? YES NO Restrictions: Handicapped accessible? YES NO If no, explain how you would accommodate a handicapped consumer: Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday 6. Name other provider(s) in your practice (if not enough space, please attach additional sheet): 7. Do nurse practitioners, physician assistants, midwives, social workers, or other non-physician providers provide care to patients in your practice? YES NO [If yes, please attach proof of professional liability insurance, proof of employment for those individuals, and a copy of their National Provider Identifier (NPI) Certification Letter.] 8. Name and address of provider(s) who share call with you (if necessary, please attach additional sheet): Name Address Name Address 9. Specify the arrangements for 24 hour/7 day coverage (apart from and in addition to Community Emergency Response Services (i.e. 911, Emergency Department, etc.): 10. Administrative Contact: (Name) (Title) (Telephone) Uniform Application to Participate Page 6 of

7 A. DEMOGRAPHIC AND PERSONAL DATA (Continued) 11. IRS requires reimbursement be made payable to name of practice affiliated with Federal Tax ID Number: Federal Tax ID Number: Name (if different from practice name) Billing Address (if different from practice address) 12. UPIN Number Medicare/Medicaid Number / 13. DEA Number Exp. Date (Attach copy to application) 14. National Provider Identifier (NPI) Number (Attach copy of NPI Certification Letter to application) COMPLETE ONLY IF LICENSED IN SOUTH CAROLINA SC Controlled Drug Substance Certificate: Expiration Date: (attach copy to application) 15. Provide the following information for each state in which you are currently or were previously licensed to practice (If necessary, please attach additional sheet): STATE DATE OF LICENSE LICENSE NUMBER LICENSE TYPE STATUS: Active, Inactive, Suspended EXPIRATION DATE / / / / / / / / / / / / / / / / PLEASE ATTACH A COPY OF EACH STATE LICENSE CERTIFICATE If provisionally licensed, provide a copy of your current supervision contract and the name and contact information for your clinical supervisor: Clinical Supervisor Street City State Zip Phone Address 16. Certification of Specialty Boards as applicable: a. If you are certified by a specialty board, indicate name of board and date of certificate. Date Certified / / Exp. Date / / Primary Specialty Board Date Certified / / Exp. Date / / Secondary Specialty Board b. Are you listed in the American Board of Medical Specialists? YES c. If you have applied to a specialty board for examination, give the name of board and the date of the scheduled examination. Date / / Uniform Application to Participate Page 7 of

8 A. DEMOGRAPHIC AND PERSONAL DATA (Continued) d. If you have not applied to a specialty board, please explain: 17. List the dates of all current professional memberships in societies, including state and county societies: FROM / TO Professional Membership Professional Membership Professional Membership Professional Membership Professional Membership (Month / Year) (Month / Year) / (Month / Year) (Month / Year) / (Month / Year) (Month / Year) / (Month / Year) (Month / Year) / (Month / Year) (Month / Year) 18. List all hospitals where you currently have privileges and indicate the type and status of those privileges: (Type: active, admitting, associate, consulting, courtesy. Status: pending, provisional, suspended, temporary, visiting) Hospital Privilege and Status of Privilege Estimated % of Admission (Primary admitting facility) 19. If you do not have admitting privileges, who admits for you? Name Address Name Address Phone Phone Uniform Application to Participate Page 8 of

9 B. EDUCATION AND PRACTICE HISTORY 1. Medical, Dental or other Professional School Attended: ( See Resume is not acceptable.) Institution Address City State Zip Degree From / / To / / Name as it appears on degree: Please attach Educational Commission of Foreign Medical Graduate Certificate - (ECFMG), if applicable. 2. Internship: Institution Address City State Zip Specialty From / / To / / 3. Residency: Institution Address City State Zip Specialty From / / To / / 4. Other Residency/Fellowship - (specify) Institution Address City State Zip Specialty From / / To / / Uniform Application to Participate Page 9 of

10 B. EDUCATION AND PRACTICE HISTORY - (Continued) 5. List work history since beginning of medical, dental or other professional school (last 5 years) and explain any employment gaps longer than 6 months; please be specific. See Resume is not acceptable. (If not enough space, please attach additional sheet) FROM / TO / Current practice Previous practice Previous practice Previous practice Previous practice (Month / Year) (Month / Year) / (Month / Year) (Month / Year) / (Month / Year) (Month / Year) / (Month / Year) (Month / Year) / (Month / Year) (Month / Year) 6. List other training and/or education (including CME) within the last three years. 7. Have you involuntarily or voluntarily withdrawn, or been suspended from any internship, residency or fellowship training program? Please explain: 8. Please explain any incident(s) in which you have involuntarily or voluntarily withdrawn your application for appointment, clinical privileges or reappointment before a decision was made by a hospital or healthcare facility s governing board. Uniform Application to Participate Page 10 of

11 C. PROFESSIONAL INFORMATION Please circle yes or no for the following questions. Please complete the attached Supplemental Form for any questions to which you answer yes. Also, please sign and date this application. If this application does not have the provider s signature, it cannot be accepted. 1. Has your license to practice in any jurisdiction ever been limited, restricted, reduced, suspended, voluntarily surrendered, revoked, denied or not renewed; have you ever been reprimanded by a state licensing agency; or are any of these actions pending with respect to your license; are you under investigation by any licensing or regulatory agency? (If yes, please complete Supplemental Question No. 1.) Yes No Y N 2. Has your professional employment or membership in a professional organization ever been subject to disciplinary proceedings, denied, limited, restricted, reduced, suspended, revoked, not renewed, or voluntarily relinquished during or under threat of termination for any reason? (If yes, please complete Supplemental Question No. 2.) 3. Has your Drug Enforcement Agency registration or other controlled substance authorization ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your registration during or under the threat of an investigation or any such actions pending? (If yes, please complete Supplemental Question No. 3.) 4. Have you ever been sanctioned or suspended by Medicare or Medicaid? (If yes, please complete Supplemental Question No. 4.) 5. To your knowledge, have you ever been reported to the National Practitioner Data Bank or the North/South Carolina Board of Medical Examiners? (If yes, please complete Supplemental Question No. 5.) 6. Have you ever been convicted of a felony or misdemeanor, or are you under investigation with respect to such conduct? (If yes, please complete Supplemental Question No. 6.) 7. Has a professional liability claim been assessed against you in the past five years, or are there any professional liability cases pending against you? (If yes, please complete Supplemental Question No. 7.) 8. Has any liability insurance carrier canceled, refused coverage, or rated up because of unusual risk or have any procedures been excluded from your coverage? (If yes, please complete Supplemental Question No. 8.) 9. Have you ever practiced without liability coverage? (If yes, please complete Supplemental Question #9.) 10. Do you currently have any medical, chemical dependency or psychiatric conditions that might adversely affect your ability to practice medicine or surgery or to perform the essential functions of your position without reasonable accommodation? (If yes, please complete Supplemental Question No. 10.) 11.Have your Hospital and/or Clinic privileges ever been limited, restricted, reduced, suspended, revoked, denied, not renewed, or have you voluntarily surrendered or limited your privileges during or under the threat of an investigation or are any such actions pending? (If yes, please complete Supplemental Question No. 11). Signature: Date: Y Y Y Y Y Y Y Y Y Y N N N N N N N N N N Uniform Application to Participate Page 11 of

12 SUPPLEMENTAL FORM All spaces in the application must be completed. (Please indicate N/A or None, if the question is not applicable) Provider Name: 1. License Limited, Reprimanded, etc. List State(s) where action took place Provider ID# (If applicable) Date(s) license revoked, suspended, etc. From / / To / / Please explain: 2. Employment/Membership Suspended, Limited, etc. List State(s) where action took place List Professional Organization Please explain: 3. Drug Enforcement Agency (DEA) Explanation List State(s) where action took place Please explain: Uniform Application to Participate Page 12 of

13 SUPPLEMENTAL FORM Provider Name: 4. Medicare/Medicaid Sanction Disciplinary Action(s) Disciplined Action(s): Provider ID# (If applicable) List State(s): Date(s) of Action From: / / To: / / Please explain: 5. National Practitioner Data Bank Report(s) Please explain the NPDB report (if you have a copy please attach): 6. Felony or Misdemeanor Did you serve a sentence? Y N If YES, circle how many years other Please explain charge and verdict List State(s) Uniform Application to Participate Page 13 of

14 Provider Name: SUPPLEMENTAL FORM Provider ID# (If applicable) 7. Named in Professional Liability Judgment, Settlement, etc. Please explain, include dates & amounts: 8. Canceled, Refused Coverage, etc. Please list Insurance Carrier(s) Please explain: 9. Practiced Without Liability Coverage Please explain: Uniform Application to Participate Page 14 of

15 Provider Name: SUPPLEMENTAL FORM Provider ID# (If applicable) 10. Medical, Chemical Dependency, or Psychiatric Conditions Please explain in detail: 11. Hospital or Clinic Privileges Revoked, Restricted, etc. List Hospital(s) Date privileges revoked, suspended, etc. From / / To / / Please explain: Uniform Application to Participate Page 15 of

16 D. OWNERSHIP INFORMATION 1. List all partners, managing employees and Electronic Funds Transfer (EFT) authorized individuals associated with your practice, and provide the information requested on each. Name and Address Title SSN License # % Owner Date of Birth: Check business relationship that applies: Owner Shareholder Partner Manager EFT Authorized Staff Check relationship to enrolling provider (if applicable): Spouse Parent Child Sibling Name and Address Title SSN License # % Owner Date of Birth: Check business relationship that applies: Owner Shareholder Partner Manager EFT Authorized Staff Check relationship to enrolling provider (if applicable): Spouse Parent Child Sibling Name and Address Title SSN License # % Owner Date of Birth: Check business relationship that applies: Owner Shareholder Partner Manager EFT Authorized Staff Check relationship to enrolling provider (if applicable): Spouse Parent Child Sibling Name and Address Title SSN License # % Owner Date of Birth: Check business relationship that applies: Owner Shareholder Partner Manager EFT Authorized Staff Check relationship to enrolling provider (if applicable): Spouse Parent Child Sibling Uniform Application to Participate Page 16 of

17 2. Do you have ownership or control interest of 5% or more in other organizations that bills Medicaid for services. Yes No If yes, please fill in the following for each organization. Organization Legal Business Name Employer Id. No. Medicaid No. Counties: Counties: Counties: Counties : ENROLLEMENT CATCHMENT AREA Please check the catchment area(s) for which you are applying: Other (please specify): Uniform Application to Participate Page 17 of

18 Attestation Statement - LIP (IMPORTANT: Submit Original Only) This Application is to be signed by each individual provider submitting an application. No Stamps or Copies Please I understand that the SHC and its representatives is responsible for the evaluation of my professional training, experience, professional conduct, and judgment. All information submitted by me or on my behalf pursuant to this Consent to Release Information is true and complete to the best of my knowledge and belief. I fully understand that any misstatement in or omission related thereto may constitute cause for the summary dismissal/denial of such participation in the Medicaid Program. I understand and agree that as an applicant for participation in the Medicaid Program, I have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubts about such qualifications. I hereby authorize SHC and its representatives to contact and/or consult with any persons, entities or institutions (including, but not limited to, hospitals, HMOs, PPOs, other group practices and professional liability carriers) which I have been affiliated, have used for liability insurance or who may have information relevant to my character and professional competence and qualifications, whether or not such persons or institutions are listed as references by me. I consent to the release and communication of information and documents between SHC and its representatives and persons, entities or institutions in jurisdictions in which I have trained, resided, practiced, or applied for professional licensure, privileges or membership in plans for the purpose of evaluation of my professional training, experience, character, conduct, ethics and judgment, and to determine professional liability insurance and/or malpractice insurance claims history. I also authorize and direct persons contacted by SHC and its representatives to provide such information regarding my character and/or professional competence and qualifications, my professional liability insurance and/or malpractice insurance claims history to representatives of the Program and I understand in doing so, I am waiving my confidentiality rights to this information. I release and hold harmless from liability all persons, entities, or institutions acting in good faith and without malice for acts performed in gathering or exchanging information in this credentialing process. This release and hold harmless provision applies to all persons, entities and institutions who will provide and/or receive, as part of the Program s credentialing process, information which may relate to my past or present physical and/or mental condition, including substance abuse, alcohol dependency and mental health information. I further authorize the release of the above information or any other information obtained from the application by a credentialing verification organization (CVO) to any health care organization designated by me or one that has entered into an agreement with the CVO where I currently have, am currently applying, or in the future will be applying for participation. I also authorize the CVO or SHC to allow my file to be reviewed by the organizations' state or national accrediting and licensing bodies. Under the penalties of perjury, I certify that: 1. The payee s Taxpayer Identification Number (disclosed on Page 1 of this application) is correct. 2. The payee is not subject to backup withholding due to failure to report interest. 3. The payee is a U.S. person. Signature of Authorization Required Information Must Be Entered For The Agreement To Be Processed I certify that the above information is true and correct. I further understand that any false or misleading information may be cause for denial or termination of participation as a Medicaid Provider. Signature of Applicant Date Print Name Title Uniform Application to Participate Page 18 of

19 SHC Network Operations Credentialing & Contracting Specialist Sandhills Center for MH, DD & SAS P O B o x 9 West End, NC Fax: SHC Provider Evaluation Form Peer (Licensed Practitioner, not partner) Referring Physician or Practitioner Supervisor Chief of Department/Staff where practitioner has admitting privileges (Not partner) Name of the Applicant: Group Name: The above provider is a SHC network applicant. Please provide us with information concerning his/her professional qualifications. All information submitted will be held in strict confidence. 1. What is your specialty/credentials? 2. What is your relationship to the applicant? 3. How long have you known the applicant? 4. How would you rate the applicant s professional abilities? Excellent Very Good Good Fair Poor 5. How would you rate the applicant s ability to work and communicate with physician and non-physician staff? Excellent Very Good Good Fair Poor 6. How would you rate the applicant s rapport with consumers/clients? Excellent Very Good Good Fair Poor 7. What do you believe to be the applicant s strengths and weaknesses (if any)? a) Strengths: b) Weaknesses: 8. To your knowledge, has the applicant had any of the following: Malpractice claim(s)? Yes No Problems with medical licensure, certification or licensing boards? Yes No Revocation, denial or change in hospital privileges? Yes No History of/or current impairment due to drugs and/or alcohol? Yes No If your answer is yes to any of the above questions, please provide details. 9. Would you recommend this person as a provider for the SHC network? Without reservation With reservation Would not recommend 10. Please provide any other information that would be helpful to us in evaluating this applicant. Evaluator s Signature: Printed Name: Address: Phone Number: Date: Group Name Street City State Zip Uniform Application to Participate Page 19 of

20 Sandhills Center Licensed Independent Practitioners Cultural, Racial, Ethnic, Gender, and Linguistic Data Form (This information will reside within SHC s Provider Directory and the online Provider Search) This form is not part of the SHC Credentialing Process. By providing the information below, you will be assisting SHC with consumer/provider matching as well as providing information necessary for analyzing our Network and its ability to meet our Consumers cultural, racial, ethnic and linguistic needs. Name of Practitioner: Name of Practice: Address: (This section is self-reported information and requires no backup documentation) Counties Served: Anson Montgomery Harnett Moore Hoke Randolph Lee Richmond Other: Provider Type: APPCNS (Advanced Practice Psychiatric Clinical Nurse Specialist) DO LCAS LCSW LMFT LPA LPC MDNP Psychiatric PA PhD PsyD Other: (please specify): Priority Populations: MH Adult SA Adult DD Adult MH Child SA Child DD Child Your Gender: Female Male Your Race and/or Ethnicity: (Please check ( ) all appropriate categories.) White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other Population(s) that you serve: (Please check ( ) all that apply) Early Childhood (0-4) Child & Adolescent (5-21) Adult (22+) Geriatrics (55+) Women Gay & Lesbian HIV/Aids Hearing Impaired Men Gender Identity Issues Sexually Reactive/Aggressive Youth Visually Impaired Other Culturally diverse populations that you feel competent to treat: (Please check ( ) all that apply) Uniform Application to Participate Page 20 of

21 White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other Practice Preference Data Language(s) you are able to communicate in fluently: (Please check ( ) all that apply) American Sign Language English French German Hmong Portuguese Russian Spanish Telugu Other (The sections below must have backup documentation to be listed with SHC) Focus of Treatments You Provide: (Please check ( ) all that apply) Amnestic Disorder Factitious Disorders Anxiety/Phobias Impulse Control Attention Deficit Hyperactivity Disorder Mentally Retarded/Developmentally Disabled Autism Asperger Obsessive-Compulsive Disorder Bipolar Disorder (manic-depressive illness) Personality Disorders Chemical Dependency/Substance Abuse Post Traumatic Stress Disorder Conduct Disorders Schizophrenia and other Psychotic Disorders Co-Occurring/Dual DX-Mental Retardation/Mental Sexual & Gender Identity Disorders Illness, Mental Health/Substance Abuse Dementia Disorder Sleep Disorders Depression Somatoform Disorders Eating Disorders Traumatic Brain Injury Clinician Expertise/Certified Specialties: (Please check ( ) all that apply) Psychological Testing Therapy/Service Type Trauma Focused Cognitive/IQ Anger Management Abuse- Physical, Sexual, and/or Emotional Developmental limited / Assessment Evaluation Maltreatment extended Career/Vocational Counseling Neglect Forensic Screening/Evaluation Cognitive Behavioral Therapy Rape Neuro Psych Personality Crisis/Solution focused Brief Therapy Dialectical Behavior Therapy Faith Based Counseling General Psychiatry General Psychology Gero Psychiatry Grief and Loss Therapy Health Psychology Chronic Medical Conditions Marriage and Family Counseling Play Therapy, Filial Relaxation/Meditation-Hypnotherapy Self-Direction Uniform Application to Participate Page 21 of

22 Practice Preference Data Clinician Expertise/Certified Specialties that Require Verification: (Please check ( ) all that apply) Verification of specific expertise(s) and/or training(s) selected below must accompany this form for SHC recognition, i.e. training certificates, certification, supervisor letters verifying training, or proof of experience. If standard training for clinician s licensure does not include area of identified expertise, additional documentation to support expertise will be required, e.g. a Psychiatrist who does psychological testing. Addiction Psychiatry (Fellowship in addiction psychiatry/board Certification/ ASAM Certification/Experience) Addiction Treatment (LCAS/CAS/CCS/ Experience) Child Psychiatry (Fellowship in Child Psychiatry/Board Certification Experience) Eye Movement Desensitization and Reprocessing Therapy (Training Certificate/experience) Forensic Psychology/Psychiatry (Fellowship in Forensic Psychiatry/Board Certification/Training/Experience) Trauma Focused Cognitive Behavioral (Course Completion at MUSC, Duke or NCTSN) Dialectical Behavior Therapy (Certification, Supervision, and Experience) Neuro Psych Assessment (Training, Supervision, and Experience) Services Provided in Office: Yes No Services Provided in the Community: Yes No Signature Date: Thank you for taking the time to submit this form. If this form is not completed and returned, your provider information will not appear within the SHC online Provider Search or Provider Handbook. Uniform Application to Participate Page 22 of