Mental Health Consultants Inc. (MHC) Provider Application To apply online, please visit our website at www.mhconsultants.com. Complete and Return to MHC: Mail: 1501 Lower State Road, Building D, Suite 200, North Wales, PA 19454 Fax: 215-343-8983 E-Mail: jmagnin@mhconsultants.com Current copies of the following documents MUST be submitted with this application: State License(s) (If psychiatrist, must include DEA and CDS licenses) Face Sheet of Professional Liability Insurance (include CAT Fund information if applicable) Current Professional Curriculum Vitae / Resume Completed IRS Form W-9 When applicable, include Educational Commission for Foreign Medical Graduates Certificate Questions regarding this application should be directed to MHC Provider Relations- 215-343-8987, ext. 1201. ******************************************************************************************* APPLICANT INFORMATION Last Name First MI Male Female Cell phone # (optional) Nickname Birth Date / / Social Security # Individual NPI# Applicant s Email Address My primary office is in my home? Yes No (do not enter office contact s email) How do you prefer to receive information? Email Mail Fax Can you conduct therapy in any language(s) other than English? Yes No If yes, please specify language(s): Ethnic Origin (optional): If this is provided, it will only be used by MHC Care Managers when requested by the patient to determine the likelihood of establishing a therapeutic alliance based upon ethnic and cultural similarities. EDUCATION College/University Degree Received Year Graduated College/University Degree Received Year Graduated Years of post-graduate experience Other Training MHC Provider Application Revised 7/20/15 Page 1 of 9
Type of Professional License LICENSURE o Counselor o Psychologist o Medical o Social Worker o Registered Nurse o Physician Assistant State License Number Year Received Expiration Date / / State License Number Year Received Expiration Date / / State License Number Year Received Expiration Date / / PROFESSIONAL CERTIFICATIONS #1 Type Year Received #2 Type Year Received PROFESSIONAL AFFILIATIONS Professional Organizations Please check all of these insurances accepted: o Blue Cross/Blue o Keystone o Aetna Shield o Cigna o Personal Choice PROFESSIONAL LIABILITY INSURANCE INFORMATION Insurance Company Name Policy Number Total Amount of Coverage $ M / $ M (include CAT fund information) Expiration Date / / Primary Office PRACTICE INFORMATION Group/Professional Name Federal Tax ID # (As listed on your W9 Tax Form) Office Address Suite City State ZIP County o My primary office is in my home (check if applicable) Phone Number ext. Fax Number Handicapped Accessible Yes No Public Transportation Yes No Your available hours- M T W Th F S Sun MHC Provider Application Revised 7/20/15 Page 2 of 9
Secondary Office (under same Tax ID#) (leave blank if none) Address Suite City County State ZIP o This office is in my home (check if applicable) Phone Number Ext. Fax Number Handicapped Accessible Yes No Public Transportation Yes No Tertiary Office (under same Tax ID#) (leave blank if none) Address Suite City County State ZIP o This office is in my home (check if applicable) Phone Number Ext. Fax Number Handicapped Accessible Yes No Public Transportation Yes No Primary Office Contact Title: Office Contact s Email Address Phone Ext. Primary Mailing Address Suite # City State ZIP Primary Payment Address Suite # City State ZIP Emergency Number /Arrangements * For any additional organizations, please complete Appendix A and submit it with this Application. MHC Provider Application Revised 7/20/15 Page 3 of 9
PRACTICE PROFILE Please notify MHC Provider Relations as soon as your practice status changes to help us keep our provider profiles up-to-date. Clinical Orientation Patient Populations Assessments Behavioral Hearing Impaired Psychological Biological / Medical Physically Disabled Persons Neurological Cognitive LGBT Worker s Compensation Cognitive Behavioral Child / Adol Family only Learning DO Electroconvulsive Therapy Families Developmental DO (ADD / ADHD) EMDR Couples Drug and Alcohol Psychoanalytic Other D.O.T. Psychodynamic Groups Psychopharmacology Psychopharmacology Disability Systems Fitness-for-Duty Other Forensic Other Groups Conducted (if checked above) Is there a particular patient population that you prefer not to work with? Treatment (please check all areas of treatment) ADD / ADHD Agoraphobia Alcohol Dependency Active Alcohol Dependency Recovering Anger Management Anxiety / Panic Bipolar Disorder Chemical Dependency Active Chemical Dep. Recovering Compulsive Gambling Conduct Disorder Cultural / Ethnic Issues Depressive Disorders Divorce / Blended Family Domestic Violence Dual Diagnosis Eating Disorders Emotional Abuse Perpetrator Emotional Abuse Victim Grief / Loss Head Trauma HIV / AIDS Related Issues Medical / Chronic Illnesses Obsessive Compulsive Disorder Pain Management PDD (Autism / Asperger s) Personality Disorders Physical Abuse Perpetrator Physical Abuse Victim Prenatal / Postpartum Issues PTSD Psychotic Disorders Sexual Abuse Perpetrator Sexual Abuse Victim Sexual Disorders Spirituality Stress Management Suboxone Suicidal Telepsychiatry Teletherapy Please list any areas of special interest and / or training not already selected above MHC Provider Application Revised 7/20/15 Page 4 of 9
Please list any treatment areas you prefer not working with Employee Assistance Program (EAP) Services (Check all that apply) o Critical Incident Response o Workshops / Seminars Other Services Provided (Check all that apply) o CID o D&A Assessments o SAP Age Groups Treated (Check all that apply) o Children ages 1-9 o Children ages 10-12 o Adolescents ages 13-19 o Adults o Older Adults Disclosure Statement Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board? Yes No Has there been any challenge to your licensure, registration or certification? Yes No Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board Yes No Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation? Yes No Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)? Yes No Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign? Yes No MHC Provider Application Revised 7/20/15 Page 5 of 9
Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program? Yes No Have any of your board certifications or eligibility ever been revoked? Yes No Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation? Yes No Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished? Yes No Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs? Yes No Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? Yes No To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank? Yes No Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)? Yes No Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct? Yes No Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or healthcare facility of any military agency? Yes No MHC Provider Application Revised 7/20/15 Page 6 of 9
Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history? Yes No Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based upon your individual liability history? Yes No Have you ever had professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years? Yes No Have you ever been convicted of, pled guilty to, or pled nolo contender to any felony? Yes No In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct? Yes No Have you ever been court-martialed for actions related to your duties as a medical professional? Yes No Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.) Yes No Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety? Yes No Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients? Yes No Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation? Yes No MHC Provider Application Revised 7/20/15 Page 7 of 9
CONDITIONS OF APPLICATION PLEASE READ CAREFULLY By applying for appointment as a Participating Provider of the MHC network, I hereby: acknowledge that I, as an applicant for membership in the MHC network, need to produce adequate information for a proper evaluation of my professional, ethical and other qualifications, for membership and for resolving any doubts about such qualifications; agree that I am submitting this application with full intentions of accepting future referrals for all MHC patients and, if I am accepted into MHC's Preferred Provider Network, I may be terminated for cause if this deems to be false; pledge to maintain an ethical practice, to provide for continuous care for my patients, and to refrain from delegating the responsibility for any aspect of the care of my patients to any practitioner not qualified to undertake that responsibility; authorize MHC, its Medical Director and their representatives to consult with prior and current associates and others who may have information bearing on my professional competence, character, health status, ethical qualifications, ability to work cooperatively with others, and other qualifications to be, and continue to be, a Participating Provider in the MHC network; consent to the inspection by MHC, its Medical Director and their representatives of all documents that may be material to an evaluation of my qualifications and competence and consent to the release of such information. I hereby release from liability MHC, its officers, directors, employees and agents for their acts performed and statements made in good faith and without malice, in connection with evaluating my application, my credentials and qualifications. In addition, I hereby release and any all individuals and organizations who provide information to MHC, its Medical Director and their representatives in good faith and without malice, concerning my professional competence, background, experience, ethics, character, utilization practice patterns, health status and other qualifications to be a Participating Provider in the MHC network. I am aware that the release from liability is an express condition to my application for, and acceptance of, membership in the MHC network, and the continuation as a Participating Provider in the MHC network; signify my willingness, if necessary, to appear for interviews in regard to my application; acknowledge that any material misstatements in, or omissions from, this application, constitute cause for denial of membership in the MHC network or cause for summary dismissal from the MHC network; recognize that the application process is a continuous process, that MHC will credential and continuously re-credential me, and that the authorizations, acknowledgments, consents, pledges and releases provided in this application will remain in effect for purposes of credentialing and recredentialing, until revoked by me in writing; submission of this application is not an assurance of acceptance in the MHC network and if I am not accepted, it is not a reflection on the quality of my practice. All information submitted by me in this application is true and complete to the best of my knowledge and belief. A photo static copy of this original statement constitutes my written authorization and request to release any and all documentation relevant to this application. Such photo static copy shall have the same force and effect as the signed original. DATE: / / PRINTED NAME SIGNATURE MHC Provider Application Revised 7/20/15 Page 8 of 9
APPENDIX A ADDITIONAL ORGANIZATION INFORMATION This form is for demographic information for each additional organization (under different Federal Tax ID#). Please make copies as needed. Professional Organization/Practice Name (As listed on your W9 Tax Form) Federal Tax ID# Primary Office Address Suite City County State ZIP o My primary office is in my home (check if applicable) Handicapped Accessible Public Transportation o Yes o Yes o No o No Phone Number Ext. Fax Number Secondary Office (under this Tax ID#) Address Suite City County State ZIP o My secondary office is in my home (check if applicable) Handicapped Accessible Public Transportation o Yes o Yes o No o No Phone Number Ext. Fax Number Office Contact Title: Office Contact s Email Address Phone Ext. Primary Mailing Address Payment Address How do you prefer to receive information? (Check all that apply) o Mail o Email o Fax Emergency#/Procedures Please check all insurances accepted at this practice: o Blue Cross/Blue o Keystone o Aetna Shield o Cigna o Personal Choice MHC Provider Application Revised 7/20/15 Page 9 of 9