PERSPECTIVES NATIONAL PROVIDER/AFFILIATE APPLICATION

Transcription

1 DIVISION OF CLINICAL OPERATIONS PERSPECTIVES EAP Updated 01/10 PERSPECTIVES NATIONAL PROVIDER/AFFILIATE APPLICATION Please PRINT or TYPE all information so it is legible. Use only blue or black ink. Do not use pencil. Failure to provide complete and accurate information may cause your application to be returned and delay processing of your application. Information submitted on this application (except for Social Security Number, IRS Individual Taxpayer Identification Number, and Date of Birth) may be available on the internet. SECTION 1 BASIC INFORMATION A. Reason For Submittal Of This Form (Check the appropriate box) 1. Initial Application 2. Change of Information (Please fill in only updated information) B. Entity Type 1. Individual 2. Group 3. Agency SECTION 2 DEMOGRAPHIC INFORMATION A. Individuals Prefix (e.g., Dr. Mrs.) First Middle Initial Last Suffix (e.g., Jr., Sr.) Credential (e.g. LCSW) Date of Birth (mm/dd/yyyy) Gender (M/F) Tax ID no. SSN (xxx-xx-xxxx) Address Line 1 Address Line 2 City State Zip Phone (xxx-xxx-xxxx) Fax (xxx-xxx-xxxx) Page 1 of 8

2 B. Organizations (includes groups, agencies and partnerships) Name (Legal Business Name) Contact Contact Contact Contact Prefix (e.g., Dr. Mrs.) First Name Middle Initial Last Name Title/ Position Address Contact Phone (xxx-xxx-xxxx) Include Extension Contact Fax (xxx-xxx-xxxx) C. Practice Information Business Mailing Address Line 1 (Street Number and Name or P.O.Box) Business Mailing Address Line 2 (e.g. Suite Number) Business City Business State Business Zip Business Phone (xxx-xxx-xxxx) Required Business Fax (xxx-xxx-xxxx) Check Here is Primary Practice Location is same as Mailing Address Business Primary Practice Location Address Line 1 (Street Number and Name P.O. Boxes not acceptable) Business Primary Practice Location Address Line 2 (e.g. Suite Number) Business City Business State Business Zip Business Phone (xxx-xxx-xxxx) Required Business Fax (xxx-xxx-xxxx) (Attach additional addresses if applicable) Office Hours Monday Tuesday Wednesday Thursday Friday Saturday Sunday - Page 2 of 8

3 SECTION 3 CLINICAL PRACTICE 1. Please mark applicable boxes: Handicap Accessible Public Transportation Accessible Appointment Availability within 24 hours Parking 2. Please indicate your primary (1) and secondary (2) therapeutic orientation: Biological/ Psychopharmacological Behavioral Cognitive Brief Treatment Psychodynamic Psychoanalytic 3. Please rank the treatment modalities you utilize from most often (1) to least often (6): Individual Group Family Marital/Conjoint Medication Management Psych Testing/ Evaluation 4. Please rank the following diagnostic categories by those you most often (1) serve to those you least often serve: Affective Disorders Alcohol/ Substance Abuse Anxiety Disorders Chronic Pain Disorders Eating Disorders Marriage/Family Problems Neuropsychiatric Disorders Personality Disorders Phobias PTSD Schizophrenia Sexual Disorders Sexual/ Physical Abuse Other: 5. Please rank the following additional specialties in the order that you work with them: Domestic Violence Dual Diagnosis Ethnic Group Gay/Lesbian Issues Geriatriccs Men s Issues Separation/ Divorce Stress Management Terminal Illness Women s Issues Other: 6. Please rank the following age groups by the frequency you work with them: Children Adolescents Adults Elderly 7. Do you speak any other languages? Yes No If yes, please specify: Page 3 of 8

4 SECTION 4 CLINICAL EDUCATION & TRAINING A. Education Information Education information should support current licensing. Name School City, State Zip Degree Year Awarded Years Post Graduate B. License & Certification Information Please list all current Licensing and Certificate Information (please attach current copy): License / Certification Certification Organization Renewal Date (mm/yyyy) License / Certification Certification Organization Renewal Date (mm/yyyy) License / Certification Certification Organization Renewal Date (mm/yyyy) License / Certification Certification Organization Renewal Date (mm/yyyy) (Please attach separate document if necessary) Page 4 of 8 SECTION 5 EMERGENCY PROCEDURES

5 What arrangements do you have for 24-hour, 7-day per week emergency coverage for your patients? Back Up Personnel Name Phone (xxx-xxx-xxxx) Include Extension Psychiatric Consultant (for non MD providers) Phone (xxx-xxx-xxxx) Include Extension SECTION 6 MALPRACTICE INSURANCE In addition to completing this information, please attach a current copy of your malpractice face sheet. Carrier or Self-Insured Name Address City State Zip Effective Date Expiration Date Policy Number Amount of Coverage per Occurrence Amount of Coverage Aggregate 1. Have you had any malpractice claims that occurred during the last five years? Yes No If yes, please discuss below. Use additional page if necessary. SECTION 7 TRAINING AND SEMINAR EXPERIENCE Perspectives is seeking affiliates that are interested in conducting trainings and seminars. If you have any training and seminar experience please list the experience that you have below. Page 5 of 8

6 Please respond to the following questions: a. Has your medical or professional license ever been revoked, suspended, or limited? b. Is there an action pending? c. Have you ever voluntarily surrendered your license? d. Has your narcotics license ever been revoked, suspended, or limited? e. Are you now, or have you been treated for alcohol or substance abuse? f. Do you suffer from any physical or mental condition which impairs your ability to practice medicine? g. Have you ever been denied hospital privileges? h. If you were granted privileges, were they ever limited, suspended, or renewal denied? i. Have you ever resigned from the staff of any hospital or medical organization because of problems regarding privileges or credentials? j. Have you ever been denied professional liability insurance or has your insurance ever been canceled or refused renewal? k. Have you ever been the subject of disciplinary proceedings by any professional association or organization? (i.e. State Licensing Boar; County, State or National Professional Society; Hospital, Medical or Clinical Staff) l. Have you ever been a defendant in any lawsuit involving a hospital or medical organization? m. Have you even been convicted of or pleaded guilty to a crime? a. Yes No b. Yes No c. Yes No d Yes No e. Yes No f. Yes No g. Yes No h. Yes No i. Yes No j. Yes No k. Yes No l. Yes No m. Yes No If you answered yes to any of the above questions, please explain on an attached sheet. SECTION 6 PSYCHIATRISTS ONLY Please list all hospitals and treatment centers where you currently have admitting staff. Identify any in which those privileges have been revoked and please explain why on a separate sheet of paper. Hospital Address Line 1 Address Line 2 City State Zip Phone (xxx-xxx-xxxx) Page 6 of 8

7 Hospital Address Line 1 Address Line 2 City State Zip Phone (xxx-xxx-xxxx) (Attach additional sheets as necessary) SECTION 7 REFERENCES Please list two professional supervisory references that you would authorize PERSPECTIVES Ltd. to contact: First Name Last Name Title/ Position Address Contact Phone (xxx-xxx-xxxx) Include Extension First Name Last Name Title/ Position Address Contact Phone (xxx-xxx-xxxx) Include Extension SECTION 8 ATTACHMENTS To insure processing of your application please include current copies of the following documents: State License DEA License (if applicable) Malpractice Face Sheet Resume/ Curriculum Vitae Addictions Certificate (where applicable) Psychiatrists- Proof of Board Certification Other Certifications you wish to have considered W-9 *For Affiliates Only* Page 7 of 8

8 SECTION 9 DISCLAIMER I acknowledge and agree that PERSPECTIVES LTD. has a valid interest in obtaining and verifying information concerning my professional competence, in determining whether to enter into an agreement with me for the provision of services to members. Accordingly, (i) (ii) (iii) I represent and warrant to PERSPECTIVES LTD. that the information contained in the foregoing application is true and complete to the best of my knowledge and belief, and I agree to inform promptly if any material change in such information occurs, whether before or after my entering into an agreement with PERSPECTIVES LTD. for the provision of medical services. I authorize PERSPECTIVES LTD. to consult with hospital administrators, members of staffs of hospitals, malpractice carriers, reference names listed above, and other persons to obtain and verify information concerning my professional competence, character and moral and ethical qualifications, and I release PERSPECTIVES LTD. and its employees and agents from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application: and I consent to the release by any person to PERSPECTIVES LTD. of all information that may reasonably be relevant to any evaluation of my professional competency, character and moral and ethical qualification, including any information relating to any disciplinary action: suspension or curtailment of privileges, and hereby release any such person providing such information from any and all liability for doing so. Signature of Applicant Print Name Date (mm/dd/yyyy) Page 8 of 8