Thank you for your interest in joining the Provider Panel. Please fill out the application below.

Organizational Providers Application

Organizational Information

Services you wish to provide*

Contact Information For Key Staff

CEO/Executive Director/Owner

Contract Manager (If Applicable)

Finance Officer/Billing-Claims Contact (If Applicable)

Recipient Rights Advisor (If Applicable)

Privacy Officer (If Applicable)

Security Officer (If Applicable)

Site Review/Auditing Contact (If Applicable)

Medical Director (If Applicable)

Provider Directory Information

Office #1

Add Office

Payment Information

Organizational Certifications/Licenses*

Add Certificate/License

Current Professional Liability Insurance Information

Insurance #1

Add Insurance

Professional References

Please provide the names and addresses of three (3) individuals who have personal knowledge of your organization over the last five (5) years and can comment on the scope/level of performance, clinical performance, satisfactory professional obligations, ethical performance, clinical judgement, and technical skills in performing procedures and in treating and managing client’s needs. Professional references only.

Reference #1

Reference #2

Reference #3