Empathia Provider Application

Empathia Provider Application For Internal Use Only: Provider ID: Group ID: Resource ID: Please complete all sections of the application. If a section is not applicable, please mark it N/A. PROVIDER INFORMATION First Name: Middle Name: Last Name: National Provider ID#: Date of Birth: Gender: M F Years Post-Master s Clinical Experience: LICENSURE (Please indicate all licenses and/or certifications in states where you currently are or have previously been licensed) Current License Class (Provider Must Be Independently Licensed): LMFT LPC LCSW APRN Psychologist Psychiatrist License Type: License #: Original Date of Issue: License State: License Expiration Date: License Type: License #: Original Date of Issue: License State: License Expiration Date: License Type: License #: Original Date of Issue: License State: License Expiration Date: Alcohol & Drug Certification: State ational CERTIFICATIONS (Please Include Copies) State: Type: Lic/Cert #: Year: Expiration: ADDITIONAL CERTIFICATIONS (Inclusive of, but not limited to CISD, Coaching, Training, etc. Please include a copy of your certificate(s) ) Certification Type: Certification #: Date of Issue: Expiration Date: Certification Type: Certification #: Date of Issue: Expiration Date: Certification Type: Certification #: Date of Issue: Expiration Date: OFFICE INFORMATION (Attach additional copies of this page for each practice address) Practice Type: Individual Group Group Practice Name (if applicable): Contact Name if a Group Practice: Contact Phone # if a Group Practice: Practice Address (include suite # if applicable): City: State: Zip Code: County: Secure Primary Phone #: Home Phone #: 24/7 Access #: Secure Email Address: Secure Primary Fax #: Secure Alternate Phone #: Tax Identification Number or Number appearing on W9 form (for billing purposes): Billing/Mailing Address (if different from practice address): City: State: Zip Code: General range of hours you are, or can be, available at this address. (Show only one range/day, whole hours [e.g. from 9 to 5]. Break and exception detail is not required.) Monday Tuesday Wednesday Thursday Friday Saturday Sunday From To From To From To From To From To From To From To Revised 9/24/2015 Empathia Provider Application Page 1

ADDITIONAL OFFICE ATTRIBUTES 1. This office is wheelchair accessible. 2. This office is close to public transportation. 3. This office is located in a home. CURRENT PROFESSIONAL LIABILITY INSURANCE INFORMATION Name of Liability Carrier: Policy Number: Effective Date: Expiration Date: $ Limit per Occurrence: $ Limit Aggregate: Length of time with Carrier: Carrier Address: City: State: Zip Code: Is this policy covered under a compensation fund? es o If yes, the name of the compensation fund: PREVIOUS 5 YEARS PROFESSIONAL LIABILITY INSURANCE INFORMATION IF DIFFERENT FROM ABOVE * REQUIRED * Name of Previous Liability Carrier: Policy Number: Original Effective Date: Expiration Date: Carrier Address: City: State: Zip Code: Carrier Phone Number:: $ Limit per occurrence: $ Limit aggregate: Name of Previous Liability Carrier: Policy Number: Original Effective Date: Expiration Date: Carrier Address: City: State: Zip Code: Carrier Phone Number:: $ Limit per occurrence: $ Limit aggregate: Highest Degree Attained: EDUCATION AND TRAINING Year Degree Awarded: Graduate School: Address: City/State/ZIP: Practice Description (Please enter up to 50 words describing your practice): PRACTICE OVERVIEW Do you work in a clinical practice for a minimum of ten hours per week? Number of supervision/consultation hours received per month: Do you keep records of all training/education you receive that can be made available to us and/or external reviewers upon request? Are you able to return client phone calls within 1 business day? Are you able to offer a routine appointment within 3 business days? Are you able to offer an urgent appointment within 1 business day? How would you rate your overall familiarity with local community resources? Excellent Good Fair PROFESSIONAL MEMBERSHIPS 1. Please list all your membership organizations that require adherence to a professional code of ethics. (Please also attach a copy of these memberships.) Revised 9/24/2015 Empathia Provider Application Page 2

INSURANCE PLAN INFORMATION Please list below the insurance plans you currently accept. CRISIS RESPONSE, SAP AND TRAINING QUALIFICATIONS Do you have formal training and/or a certification in Trauma Response Services (i.e., AAETS, FAA, HRM, ICISF, NOVA, Red Cross, other certification)? If yes, attach latest proof of trainings/certificates. Number of years of onsite Trauma Response Service experience: Number of onsite Trauma Responses within the past two years: Ability to be onsite to provide services within 24-72 hours? Types of Trauma Response Services you have performed? Robbery Death of Employee Downsizing atural Disaster Suicide Terrorism Other Please list national networks for which you are a crisis consultant: Are you a qualified Substance Abuse Professional (SAP) under Department of Transportation (DOT) regulations of 1/1/04? If yes, please explain your experience and include documentation of training and test completed. Do you have experience providing EAP training? Are you able to provide EAP training? Years of training experience: Hours of training you provide per month: Type of trainings delivered: Coaching Stress Management Wellness Work-Life Balance Other Audience: Employees Executive Management HR Staff Union Stewards Other Are you a Certified Employee Assistance Professional (CEAP)? (If yes, please include a copy of your certificate.) EAP EXPERIENCE CEAP Certificate #: Date of Issue: Expiration Date: Are you an Employee Assistance Specialist Clinical (EAS-C)? (If yes, please include a copy of your certificate.) EAS-C #: Date of Issue: Expiration Date: Are you a member of the Employee Assistance Professionals Association (EAPA) or Employee Assistance Society of North America (EASNA)? EAPA or EASNA Membership #: Expiration: I have experience providing employee assistance counseling. Total years of EAP experience (number): Percent of practice currently delivering EAP services as a provider or affiliate: % I am qualified and experienced in providing solution-focused counseling. I am qualified to provide general assessments, short-term problem-resolution counseling, and/or referrals for: Mental Health Relationships, Family & Children Within Family Alcohol/Drug Addiction I am experienced in identifying and resolving workplace problems that may be caused or exacerbated by an employee's personal or work life. I have experience and understanding of dual client relationships where one is simultaneously serving both the client, recipient of sessions, and the client company, payer of the service. I have knowledge and experience with assessing and managing high-risk situations (e.g., suicidal, homicidal, or self-injury). Please list EAPs where you have been or for which you are providing services (include dates and length of services provided). Revised 9/24/2015 Empathia Provider Application Page 3

SESSION FORMAT (CHECK ALL THAT APPLY) Individual Couples Family Group Online e-counseling Telephonic Video Other TREATMENT APPROACH (CHECK ALL THAT APPLY) Biofeedback/Neurofeedback Brief Therapy CBT EMDR Family Systems Group Hypnosis Psychodynamic Psychoeducational Rational Emotive Therapy Solution Focused Other: CLIENT DEMOGRAPHICS (CHECK ALL THAT YOU ARE EXPERIENCED IN SERVING) Child Below 6 Child 6 12 Adolescent Adult Geriatric African American Asian American Caucasian Christian Gay & Lesbian Latino American Military LANGUAGES SPOKEN OTHER THAN ENGLISH American Sign Language Cantonese French Japanese Mandarin Russian Spanish Other OPTIONAL, VOLUNTARY, AND NOT REQUIRED The following information regarding sexual orientation, religious affiliation, and race/ethnic group is not used for purposes of denying an application for participation. Often clients will ask for a counselor who meets a specific preference within one of the following categories. If your application is approved, and you provide this information, your response will be entered into our database so that you can be identified if a client requests a counselor who meets a specific category. Any responses you provide or your decision to not provide this information will not be the basis for denying your application for participation. Are you willing to identify your religious background for clients requesting an EAP counselor with your specific religious background? Catholicism Christianity Eastern Religion Jewish Islam Other Are you willing to identify your sexual orientation for clients requesting an EAP counselor with your specific orientation? Bisexual Gay Transgender Heterosexual Are you willing to identify your military experience for clients requesting your background? If so, are you a Veteran? Are you willing to identify your ethnicity and/or nationality for clients requesting an EAP counselor with your specific background? African American Arab American Hispanic ative American Asian, Pacific Islander Israeli Caucasian Other Business Status: Minority-Owned Business* Women-Owned Business* 8(a) certified (as defined by SBA) Very Small Business Enterprise (VSBE) Service-Disabled Veteran-Owned Small Business* Veteran-Owned Business* HUBZone Program (Check any that apply *Must be 51% owned, operated and controlled to qualify) Revised 9/24/2015 Empathia Provider Application Page 4

TREATMENT SPECIALTIES (CHECK ALL THAT APPLY) ACOA/Codependency Coaching Life Fitness for Duty Psychoses Abuse Coaching Wellness Gay/Lesbian (LGBT) Psychosomatic Illnesses ADD/ADHD Codependency Gender Identity Relationship/Intimacy Addiction Cognitive Disorder Geriatric Issues Schizophrenia Adjustment Disorders Couples/Marital Grief/Loss/Bereavement Self-Esteem Adolescents Cross Cultural Hearing Impairment Sexual Abuse/Rape/Incest Adoption Depression HIV/AIDS Sexual Compulsivity Aging Developmental Disorders Identity Disorder Sexual Disorders Alcoholism Disability Impulse Behavior Disorder Sexuality Anger Management Discrimination Learning Disabilities Sleep Disorders Anxiety Disorders Dissociative Disorder Legal Smoking Cessation Autism Divorce Life Transitions Speech Disorder Bipolar Disorder Domestic Violence Mediation, including Divorce Spiritual Counseling Body Image Drug-Free Workplace Medical Issues Stress Management Career Counseling Dual Diagnosis Men s Issues Substance Abuse Child Abuse EAP Trainer Mood Disorders Tourette s Syndrome Child Custody Eating Disorders Obsessive Compulsive (OCD) Training Childhood Trauma EMDR Online Training Trauma Child of Alcoholism Emotional Abuse Personal Growth Trauma Response/CISD Children s Issues Employee Assistance Personality Disorders Veterans Issues Christian Counseling Family Issues Phobias Women s Issues Chronic Illness Fertility Post-Traumatic Stress (PTSD) Work Issues Coaching Executive Financial Psychological Testing Other REFERENCES (OUTSIDE CURRENT PRACTICE/AT LEAST ONE REFERENCE FROM AN EAP PROFESSIONAL IS PREFERRED) Name & Title: Name & Title: Agency: Agency: Phone: Phone: Relationship to Applicant: Relationship to Applicant: Revised 9/24/2015 Empathia Provider Application Page 5

DISCLOSURE If you answer YES to any of the following questions, you are REQUIRED to provide: (1) a detailed explanation of your involvement, (2) the date the action was initiated, (3) the current status, including any final outcome, (4) amount of judgment/settlement or adverse decision, AND (5) a copy of any court order, consent order and findings, settlement agreement or other documentation regarding the current status or final resolution for each matter. If a matter is pending, include a letter from your attorney providing detailed information regarding current status of the matter and copies of any related documentation such as an indictment, statement of charges, Summons & Complaint, answer, etc. 1. Have you ever been convicted of a misdemeanor related to your professional functions? 2. Have you ever been charged or convicted of a felony in any state? 3. Have you ever been investigated by any professional or licensure board, professional association, private payor, state or federal regulatory agency, or other authority? 4. Has your clinical license, certification, DEA, CDS, or ability to practice in any jurisdiction ever been stipulated, denied, restricted, suspended, reduced, revoked, not renewed, placed on probation, or otherwise limited in any way by a licensing agency or other regulatory bodies? 5. Have you ever voluntarily relinquished your professional license, certification or other authority to practice for any reason, including as an alternative to disciplinary action? 6. Are you aware of any formal disciplinary or criminal charges pending against you? 7. Are you aware of any complaints against you filed with any licensing, certification, or other regulatory body? 7a. Has it ever been determined that you have operated outside the recognized boundaries of your professional competencies? 7b. Has your employment, hospital privileges, managed care organization or EAP participation, or other privileges or participation status ever been denied, restricted, suspended, reduced, revoked, not renewed, placed on probation or otherwise limited in any way? 8. Have you ever been involuntarily terminated from professional employment or a hospital staff, or, terminated by a managed care organization, EAP or any other organization that granted you privileges or participation status? 9. Have you ever resigned with knowledge of an investigation about you by a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status? 10. Are you aware of any disciplinary actions that have been initiated against you by a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status? 11. Are you aware of any complaints against you filed with a professional employer, hospital staff, managed care organization, EAP or any other organization that granted you privileges or participation status? 12. Has a professional liability carrier ever denied, limited, not renewed or canceled your coverage? 13. Are you now or have you ever been sanctioned or excluded from federal, state or local government programs? 14. Have any malpractice suits, professional liability suits, arbitration or other proceedings ever been instituted against you? ABILITY TO PERFORM ESSENTIAL JOB FUNCTIONS 1. Are you able to perform the essential functions of a practitioner in your area of practice? 2. Do you require accommodations in order to perform these functions? If yes, please explain: 3. Are you currently engaged in the illegal use or abuse of drugs or controlled substances? If yes, please explain: 4. Do you have any reason to believe that you would pose a risk to the safety or well being of your patients? If yes, please explain: Revised 9/24/2015 Empathia Provider Application Page 6

Authorization and Release Statement I hereby authorize the Credential Verification Organization (the CVO) to consult with any representative(s) of the medical/professional or administrative staff of any health care organizations with which I have or have had employment, practice, association or privileges, and any other organizations (including without limitation state licensing boards and the National Practitioner Data Bank) or individuals who have information bearing on my credentials, competence, professional performance, clinical skills, judgment, character and ethical qualifications, and to inspect such records which shall be material to the evaluation of my professional qualifications and competence to carry out the privileges I am requesting, as well as to my moral and ethical qualifications. I hereby authorize any health care organizations with which I have or have had employment, practice, association or privileges, and any other organizations (including without limitation state licensing boards and the National Practitioner Data Bank) or individuals who have information bearing on my credentials, competence, professional performance, clinical skills, judgment, character and ethical qualification to provide and/or release information (both written and oral) to representatives of the Credential Verification Organization (the CVO) bearing on my credentials, competence, professional performance, clinical skills, judgment, character and ethical qualifications. Such information includes but is not limited to information regarding any and all malpractice actions, pending or final disciplinary actions and alterations in privileges, and any information with respect to whether I am able to perform the essential functions of the position for which I have applied or the privileges I have requested with or without a reasonable accommodation, according to accepted standards of professional practice and without posing a direct threat to patients or staff (including without limitation information regarding any impairment due to the use of drugs or alcohol). I authorize and request my medical malpractice liability insurance carrier to release information to the Credential Verification Organization (the CVO) regarding any claims or actions for damages pending or closed, whether or not there has been a final disposition. I hereby release from liability any and all individuals and organizations that, in good faith and without malice, provide information to the Credential Verification Organization (the CVO) for the purpose of verifying my background, experience, qualifications, and credentials. I also hereby release from liability the Credential Verification Organization (the CVO) for their acts performed in good faith and without malice in connection with the evaluation of my professional skills, competence, character, credentials and qualifications and the exchange of information with respect to my professional skills, competence, character, credentials and qualifications. I agree that a photocopy of this Authorization and Release Statement will be as valid as the original, and that this Authorization and Release Statement will remain valid unless revoked by me in writing, or the date on which the Credential Verification Organization (the CVO) next conducts recredentialing. Signature: Printed Name: Date: Revised 9/24/2015 Empathia Provider Application Page 7