Individual or Group Application for Affiliate Network

Transcription

1 Individual or Group Application for Affiliate Network If you are an organization or group practice and do your own credentialing just one application is needed. Please list all counselors below. PLEASE RETURN TO: Alternatives EAP LLC Affiliate Relations 1627 Main St., Suite 1100 Kansas City, Missouri Phone: Ext 1 Fax: Name (Individual or Group Practice): Office Address: ALONG WITH THE FOLLOWING FOR EACH GROUP MEMBER: 1. Resume(s) 2. Copy of diploma(s) 3. Copy of current license(s) and certification(s) 4. Verification of business and liability insurance ($1M and $3M minimum) 5. Copy of completed and signed W-9 (s) Mailing Address (if different): Telephone: Fax: Cell: (Required): What is the best way to reach you in an urgent situation during business hours? What is the best way to reach you in an urgent situation after-hours/weekends? What number does the employee/family member call to make an appointment? Is your office handicap accessible? Yes No Is public transportation available Yes No Are you or someone in your group SAP qualified? Yes No Are you or someone in your group CEAP (Certified Employee Assistance Professional) certified? Yes No Can you or your group provide chemical dependency evaluations? Yes No Are you or your group available to provide on-site critical incident management consultations? Yes No Are you or your group available to provide any basic organizational development services such as conflict resolution or team building? Yes No Other please specify: Are you or your group available to provide on-site training and education sessions? Yes No Please specify Topics: Counselor Name Degree Years in Practice Years of EAP Experience Specialties Second Language Page1

2 INDIVIDUAL OR GROUP AFFIDAVIT AND RELEASE OF INFORMATION 1. Have you or anyone in your group ever been notified by any state, territory, district, country, U.S. government agency, or state-licensing board of any complaint filed against them? This includes, but is not limited to, any allegations currently pending. Yes No If yes, please explain on a separate sheet. 2. Has any disciplinary action ever been taken against you or anyone in your group regarding licensure? This includes any disciplinary actions by the U.S. military, U.S. Public Health Service, or other U.S. federal governmental entity. (Disciplinary actions include, but are not limited to, suspension, revocation, probation, practice limitations, reprimand, letter of admonition, censure, and any allegations currently pending.) Yes No If yes, please explain on a separate sheet. 3. Have you or any member of your group ever had staff privileges limited or reduced, denied, suspended or revoked, or has resigned from a staff position in lieu of disciplinary action? Yes No If yes, please explain on a separate sheet. 4. Have you or a member of your group ever been convicted of, or pled guilty or nolo contendere to, any felony in any state, territory, district, the U.S., or foreign country? Yes No If yes, please explain on a separate sheet. 5. Have you or a member of your group ever entered into a malpractice settlement or had any malpractice judgment entered against you in a court of law? Yes No If yes, please explain on a separate sheet. 6. I affirm that as an organization or a group practice, that all practitioners who provide services are at a minimum, masters level, licensed and credentialed by the organization. 7. Have you ever been terminated or removed from a panel or EAP organization? Yes No If yes, please explain: I affirm that the information I have provided above regarding myself or the group is true and accurate. I understand that Alternatives will investigate my/our licensure status with the state(s) in which I or our group/agency is licensed to practice professionally, as well as other certification(s) and/or staff privileges represented herein. I also understand that Alternatives will use other subjective and objective criteria in evaluating my/our application(s) and has a right to reject any application. Applicant's Signature Date Page2

3 1627 Main Street, Suite 1100 Kansas City, Missouri Fax AlternativesEAP.com Dear Colleague: Since 1982, Alternatives has been delivering innovative EAP services through a network of meticulously selected partner affiliates who we believe share our same philosophy regarding excellence in workplace based programs. Thank you for agreeing to be part of our team and the opportunity to partner with you to deliver EAP services in your community. I sincerely believe you will find us to be very easy to work with, ask for an absolute minimum of paper work, and reimburse you for your services in a very timely fashion. As part of its credentialing process, Alternatives will verify education and licensure, and conduct a search through the National Practitioner s Data Bank. The Professional Affidavit and Release of Information that is enclosed will need to be signed and dated, as it is necessary for us to perform the credentialing process. Please visit our Web Site at alternativeseap.com and click on Affiliate Provider Information to obtain a copy of our Affiliate Manual and get copies of other support materials. Again, thank you for being a part of our network team, we are looking forward to a mutually beneficial working relationship. If you have any questions, or I can clarify any of the finer points, my direct dial number is ext Sincerely, Terri Gimlin President/CEO Page3

4 Affiliate Partnership Agreement This Agreement is entered into this day of, 20 by and between Alternatives, Inc, 1627 Main St., Suite 1100, Kansas City, Missouri, ("Alternatives") and, herein referred to as "Affiliate Partner". In consideration of the covenants set forth herein and other valuable consideration, the sufficiency of which is hereby acknowledged, Alternatives and Affiliate Partner hereby agree as follows: I. Affiliate Partner agrees: A. To provide the EAP services outlined in Exhibit I. B. To follow Alternatives working protocols and to use the Case Information Form (CIF) when performing professional services for Alternatives Clients. Certain Alternatives Client employees, dependents, and significant others (herein referred to as "Client employees") referred to Affiliate Partner may require modification of standard policies and procedures. Deviations from Alternatives standard policies and procedures must be approved by Alternatives in advance. C. To direct bill Alternatives for all professional services performed in accordance with the rate(s) shown in Exhibit I. Affiliate Partner agrees to not bill the client for any reason. Alternatives will not reimburse for any services that are more than six (6) months old. D. To promptly forward the Clinical Information Form for Alternatives Client employees and family members to Alternatives at the conclusion of the case (attached as Exhibit II). Affiliate Partner should obtain from each Client employee referred to Affiliate Partner an authorization which is compliant with the Health Insurance Portability and Accountability Act of 1996 ( HIPAA ) or any other document required by local/state statute. E. To maintain for the duration of this Agreement, at minimum $1,000,000.00/$3,000, professional liability insurance in force while providing services to Alternatives Client employees, and to provide Alternatives with evidence of such coverage. F. That because Alternatives Client employees originally contact Alternatives for EAP services and because of the contractual relationship between Alternatives and Affiliate Partner, there is no confidentiality requirement regarding communications or information exchanged between Alternatives and Affiliate Partner with respect to said covered members. G. Affiliate will maintain a complete clinical, administrative and financial file relating to services provided to Alternatives Client employees and family members pursuant to this agreement and the licensing and certification of Affiliate as a professional and in accordance with state and federal law. The file will also contain any necessary releases of confidential information. Alternatives will have the right to inspect and make copies of these records during the contract period and as required by law, for a period of up to seven years. H. To assure that said Client employee is considered an Alternatives Client/Client employee unless Alternatives designates otherwise in writing to Affiliate Partner Page4

5 I. To keep strictly confidential all information concerning Alternatives Clients, Client employees and the terms, including pricing, of the business relationship between Alternatives and Affiliate Partner. J. To refrain from engaging in any activity that may adversely interfere with the business relationship between Alternatives and its Clients. K. That upon termination of the relationship between Affiliate Partner and Alternatives and for a one (1) year period after termination of said relationship for any reason, Affiliate Partner will not personally interfere with the business relationship between Alternatives and its Clients. L. Affiliate Partner will notify Alternatives regularly of any changes, updates or renewals of insurance, licenses, certifications, pending lawsuits, etc. Alternatives will re-credential every three years. II. Affiliate Partner warrants: A. The assigned practitioner will render the highest possible level of care in providing the professional EAP services set forth in this Agreement. B. All professional services provided to Alternatives Client covered employees pursuant to this Agreement shall be provided by experienced, competent, professional personnel who hold at least a Master's degree in psychology, social work, counseling, or a related discipline, are licensed/credentialed to practice in their respective State, and have short-term EAP counseling experience. C. Alternatives shall have the exclusive rights to bill and collect fees from Client organizations of Alternatives for services rendered to their employees/dependents/significant others pursuant to this Agreement. Affiliate Partner warrants that they will not attempt to collect any co-pay, deductible, or fee of any kind from the covered member or the client company. D. That Affiliate Partner shall not directly or indirectly communicate with any Alternatives Client organizations or their personnel with respect to any Alternatives Client employees, and shall submit any and all such proposed communications through Alternatives unless Alternatives agrees that Affiliate Partner may do so. E. Affiliate Partner agrees to never recommend time off for any reason for the covered member without consultation with the Alternatives Vice President of Clinical Services. III. Alternatives agrees: A. To furnish to Affiliate Partner with a copy of Alternatives Affiliate Manual, CIF forms, and any other information needed to service the covered member. B. To promptly remit payment within thirty [30] days to Affiliate Partner upon receipt of appropriate invoice. C. To keep strictly confidential the terms of the business relationship between Alternatives and Affiliate Partner. D. Other terms and/or provisions as set forth in Exhibit I and II IV. Affiliate Partner in performing the services contemplated herein shall for all purposes be deemed an independent contractor. In no event shall this Agreement be construed to create a partnership, agency, joint venture, employment or other similar relationship between the parties Page5

6 V. Affiliate Partner agrees to fully indemnify and hold harmless Alternatives, its officers, directors, representatives, shareholders, and employees for all claims, demands, and losses, including costs and attorney's fees, arising out of or related to this Agreement and any services performed pursuant to this Agreement for services provided by Affiliate Partner. Alternatives agrees to fully indemnify and hold harmless Affiliate Partner, its officers, directors, representatives, shareholders, and employees for all claims, demands, and losses, including costs and attorney's fees, arising out of or related to this Agreement and any services performed pursuant to this Agreement for services provided by Affiliate Partner. VI. VII. This Agreement shall be interpreted, construed, and governed according to the laws of the State of Kansas. This Agreement shall supersede any oral and written statements or agreements relating to the items covered in this Agreement and shall constitute the complete Agreement between Alternatives and Affiliate Partner. No modification of this Agreement is binding upon Alternatives or Affiliate Partner unless it is expressly agreed to in writing and signed by Alternatives and Affiliate Partner. If any provision of this Agreement is in conflict with any existing or future state or federal law, such provision of this Agreement shall be severable, and the remainder of this Agreement shall not be impaired and shall remain in full force and effect. This Agreement shall be in effect upon the affixing of signatures hereto and may be terminated by written thirty (30) day notification of either party, by mutual agreement of the parties. IN WITNESS WHEREOF, the parties hereto have executed this Agreement as of the date and year first above written. Alternatives EAP, LLC Terri Gimlin, President/CEO 1627 Main St., Suite 1100 Kansas City, Missouri, ext Individual or Group Name: Terri Gimlin, President/CEO Signature Date Date Page6

7 Group Attestation On behalf of, I attest that this agency maintains current licensure for each clinician who provides services for clients referred through Alternatives EAP by checking the box below. Current licensure: Yes Licensure is maintained on file at this agency and can be provided upon request to Alternatives EAP. Does your company carry the malpractice insurance on each clinician providing services or does each individual clinician carry his/her own malpractice insurance? Please mark the appropriate box. Malpractice insurance is carried by the Company: Yes No Individual clinician carries his/her own malpractice insurance: Yes No Please attach the appropriate Certificate of Insurance (Proof of Coverage). Administrator Date Page7

8 Affiliate Partnership Agreement Exhibit I: Reimbursement Schedule A. Services to be provided by Affiliate Partner: 1. Assessment, short term counseling, and referral (if needed) of referred covered member for personal problems including, but not limited to, chemical dependency, emotional/psychiatric problems, marital, family, and relationship problems. Covered members are entitled to a maximum number of sessions based on their employer's contract with Alternatives. This information will be supplied to the Affiliate Partner when a covered member is referred. 2. Will see referred Client employees within two to three business days or at the client s choosing, whichever is best. 3. If agreeable, perform on-site critical incident management, conflict resolution, education, and training activities at client locations as specified by Alternatives. 4. If agreeable will provide Substance Abuse Professional Services (SAP). B. Alternatives agrees to reimburse Affiliate Partner for services at the following rates: 1. Assessment, referral, short-term counseling, and $ per hour. 2. On-site Critical incident $ per hour 3. Conflict resolution, education, and $ per hour 4. Travel when approved by $ per mile Affiliate Provider acknowledges and agrees to this fee schedule. (Initials Please) Affiliate Provider agrees to remind all Alternatives clients to visit our website alternativeseap.com and complete the Satisfaction Survey after the conclusion of the first session. (Initials Please) Page8

9 Affiliate Partnership Agreement Exhibit II: Sample forms with links A. Sample Client Information Form B. Sample Services Authorization C. Alternatives Affiliate Manual D. Sample EAP Services Brochure Page9