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    Checklist For Enrollment of Providers

    Uploaded by

    Maria Crayton Haliburton
    The document is a checklist for provider credentialing that includes sections for personal and professional information such as name, license, education, address, specialty areas, treatment modalities, and disorders/issues treated. The checklist requests copies of identification, licenses, degrees, malpractice insurance, and references to be provided for credentialing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Checklist For Enrollment of Providers

    Uploaded by

    Maria Crayton Haliburton
    79 views7 pages
    The document is a checklist for provider credentialing that includes sections for personal and professional information such as name, license, education, address, specialty areas, treatment modalities, and disorders/issues treated. The checklist requests copies of identification, licenses, degrees, malpractice insurance, and references to be provided for credentialing.

    Original Description:

    Checklist for providers

    Original Title

    Checklist for Enrollment of Providers (1)

    Copyright

    © © All Rights Reserved

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    The document is a checklist for provider credentialing that includes sections for personal and professional information such as name, license, education, address, specialty areas, treatment modalities, and disorders/issues treated. The checklist requests copies of identification, licenses, degrees, malpractice insurance, and references to be provided for credentialing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    79 views7 pages

    Checklist For Enrollment of Providers

    Uploaded by

    Maria Crayton Haliburton
    The document is a checklist for provider credentialing that includes sections for personal and professional information such as name, license, education, address, specialty areas, treatment modalities, and disorders/issues treated. The checklist requests copies of identification, licenses, degrees, malpractice insurance, and references to be provided for credentialing.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 7

    CHECKLIST FOR PROVIDER CREDENTIALING

    Your Name and License Type___________________________________

    CAQH ID _____________________

    login:_____________________

    password:_________________________
    ____ Copy of TDL or ID

    ____ Copy of Professional License (large w/o the card and with the carry card by itself)

    ____ All names ever used, including middle name (i.e. maiden, etc)

    ____________________________________________________

    ____ SSN_______-_____-________

    ____ NPI number (Type 1- Individual) (Type 2 -Organizational)

    ____ Copy of degrees earned (Masters and above)

    If degree not available: Name of degree and school for highest level achieved:

    __________________________________

    Start: Month/Year___________

    End: Month/Year___________

    ____ Home address and phone number

    _________________________________________

    _________________________________________

    Phone: _________________________________________

    ____ 3 professional references w/addresses and phone numbers/email address

    1.

    2.
    3.

    ____ Copy of Resume/Vitae

    ____ Signed copy of a W-9 (I will complete the form field, just sign and scan; found on
    irs.gov)

    ____ Copy of Malpractice Insurance

    Please check of areas of specialty and interest (see form attached)

    What is your age limit/gender limit?______________

    Do you hold any special certifications? (please attach)

    ________________________________________
    Populations and Settings
    Treated
    Adolescents

    Adults Homelessness

    Blind/Visually Impaired Mobile Crisis

    Children Nursing Home

    Serious Mental Illness Home Based

    Deaf/Hearing Impaired Hospital Based

    Developmental Disability Telemedicine

    Emotionally Disturbed Community Based

    Gay/Lesbian School Based

    Geriatric

    Women

    Young Children

    Severe Persistent Mentally Ill

    Physical Disability

    Men
    Treatment
    Modalities/
    Approaches
    Applied Behavioral Analysis (ABA)

    Addictive Disorders

    Adolescent Psychotherapy

    Adolescent Sex Offender

    Adolescent Psychiatry

    Adoption Issues Medication Management

    Alcohol/SA Treatment Mood Disorders


    Methodone/Suboxone

    Anger Management Neuropsychological Testing

    Art Therapy Neuro-Linguistic Programming


    (NLP)

    Attachment Therapy Outcomes Oriented Therapy

    Behavioral Therapy Parent Child Interaction Therapy


    (PCIT)

    Brief Therapy Play Therapy

    Biofeedback Psychological Testing

    Chemical Dependency Assessment Psychoanalytic Therapy

    Child Parent Psychotherapy (CCP) Psychodynamic Therapy

    Child Psychological Testing Psychopharmacology

    Christian Counseling Pain Management


    Client Centered Therapy Rationale Emotive Therapy

    Cognitive Therapy Relapse Prevention

    Couples Therapy Relationship Disorders

    Crisis Intervention/Stabilization Sensory Processing/Integration

    Critical Incident Debriefing Sexual Compulsions/Addictions

    Cognitive Rehab Therapy Sex Therapy

    Child Psychiatry Solution Empowerment Therapy

    Dialectical Behavioral Therapy Stress Management

    Developmental Evaluation Tobacco

    Domestic Violence Cognitive Behavioral Therapy

    ECT Trauma Focused- CBT Assessment Trauma Informed


    Care (TIC)

    EMDR Trauma Focused Trust Based Relational


    Intervention (TBRI)

    (TF-CBT) Weight Management

    Tobacco Cessation

    Family Therapy Impulse disorders

    Family Systems Inpatient Attending

    Gay/Lesbian/Bisexual Inpatient Consult MD

    Group Therapy Hypnosis

    Geriatric Psychiatry Intensive Family Intervention

    Gestalt Individual Therapy

    Intake Assessment Intensive Outpatient


    Disorders/Issues
    Addictive Medicine Learning Disability

    ADD/ADHD Infertility Medical Evaluation

    Addictive Disorders Medical Illness/Chronic Illness

    Adjustment Disorder Men Issues

    Adolescent Behavior Disorders Mood Disorders

    Adoption Issues Marital Issues

    Adult ADD Mental Retardation

    AIDS/HIV Obsessive Compulsive Disorder

    Anger Management Oppositional Defiant Disorder

    Anxiety/Panic Disorder Organic Mental Disorder

    Attachment Disorder Parenting Issues

    Autism/Aspergers Personality Disorders

    Bipolar Disorders Post-Partum Disorder

    Chemical Dependency PTSD

    Christian/Spiritual Panic Disorder

    Chronic Pain/Pain Management Phobias

    Crisis Stabilization Physical Abuse

    Cultural Issues Reactive Attachment Disorder

    Child/Parent Bonding Relapse Prevention

    Co-occuring Disorders Sexual/Physical Abuse (Adults)

    Cognitive Disorder Sexual/Physical Abuse (Children)

    Concussion Schizophrenia
    Criminal Offenders Serious/Persistent Mental Illness

    Dementia Disorders Sexual Disorders

    Developmental Disorder Sexual Dysfunction

    Disruptive Behavior Sexual Abuse/Incest

    Dissociative Disorder Sleep Disorder

    Separation/Divorce Step/Blended Families

    Domestic Violence Stress Management

    Dual Diagnosis Self Injury

    Depression Sexual Offender

    Disabled Substance Abuse

    Eating Disorders Suicide

    Equine Assisted Therapies Tobacco Cessation

    Family Dysfunction Women Issues

    Feeding Disorders Work Related Problems

    Gay/Lesbian/Bisexual

    Gender Identity Issues

    Grief/Loss/Bereavement

    Head Trauma

    Home Visits

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