Individual Practitioner  Application

Current copies of the following documents MUST be submitted with this application:

  • State License(s) (If psychiatrist, must include DEA and CDS licenses)
  • Face Sheet of Professional Liability Insurance (include CAT Fund information if applicable)
  • Current Professional Curriculum Vitae / Resume
  • Completed IRS Form W-9
  • When applicable, include Educational Commission for Foreign Medical Graduates Certificate

Questions regarding this application should be directed to MHC Provider Relations at  providerrelations@mhconsultants.com.

 

Individual Provider Application

Applicant Information

Provider's Name
Provider's Name
First
Last
How do you prefer to receive information?
Can you conduct therapy in any language(s) other than English?
If this is provided, it will only be used by MHC Care Managers when requested by the patient to determine the likelihood of establishing a therapeutic alliance based upon ethnic and cultural similarities.

Education

Licensure

Professional Certifications

Professional Affiliations

Please check all insurances accepted:

Professional Liability Insurance Information

(include CAT fund information)

Practice Information

Please enter your business name as shown on your W-9.
Primary Office Contact
Primary Office Contact
First
Last
Primary Office
Office Address
Office Address
City
State/Province
Zip/Postal
Is this a home office?
Is is handicapped accessible
Is it accessible by public transportation?
Telehealth or In-person Services Offered
Is the Mailing address the same as the Primary Office address?
Mailing Address
Mailing Address
City
State/Province
Zip/Postal
Is the Payment address the same as the Primary Office Address?
Payment Address
Payment Address
City
State/Province
Zip/Postal
Secondary Office

(under same Tax ID#) (leave blank if none)

Office Address
Office Address
City
State/Province
Zip/Postal
Is this a home office?
Is is handicapped accessible
Is it accessible by public transportation?
Telehealth or In-person Services Offered
Tertiary Office

(under same Tax ID#) (leave blank if none)

Office Address
Office Address
City
State/Province
Zip/Postal
Is this a home office?
Is is handicapped accessible
Is it accessible by public transportation?
Telehealth or In-person Services Offered

Practice Profile

Please notify MHC Provider Relations as soon as your practice status changes to help us keep our provider profiles up-to-date.

Clinical Orientation
Patient Communities
Assessments/Specialty Services
Treatment Areas (please check all areas of treatment)
Employee Assistance Program (EAP) Services (Check all that apply)
Other Services Provided (Check all that apply)
Age Groups Treated (Check all that apply)
Do you have the ability to submit claims electronically?

Disclosure Statement

Please read and answer the following questions carefully.
Has your license, registration or certification to practice in your profession ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board?
Has there been any challenge to your licensure, registration or certification?
Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions (for reasons other than non-completion of medical record when quality of care was not adversely affected) or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?
Have you voluntarily or involuntarily surrendered, limited your privileges or not reapplied for privileges while under investigation?
Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?
Were you ever placed on probation, disciplined, formally reprimanded, suspended or asked to resign during an internship, residency, fellowship, preceptorship or other clinical education program? If you are currently in a training program, have you been placed on probation, disciplined, formally reprimanded, suspended or asked to resign?
Have you ever, while under investigation or to avoid an investigation, voluntarily withdrawn or prematurely terminated your status as a student or employee in any internship, residency, fellowship, preceptorship, or other clinical education program?
Have any of your board certifications or eligibility ever been revoked?
Have you ever chosen not to re-certify or voluntarily surrendered your board certification(s) while under investigation?
Have your Federal DEA and/or State Controlled Dangerous Substances (CDS) certificate(s) or authorization(s) ever been challenged, denied, suspended, revoked, restricted, denied renewal, or voluntarily or involuntarily relinquished?
Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental health care plans or programs?
Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?
To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or Healthcare Integrity and Protection Data Bank?
Have you ever received sanctions from or are you currently the subject of investigation by any regulatory agencies (e.g., CLIA, OSHA, etc.)?
Have you ever been convicted of, pled guilty to, pled nolo contendere to, sanctioned, reprimanded, restricted, disciplined or resigned in exchange for no investigation or adverse action within the last ten years for sexual harassment or other illegal misconduct?
Are you currently being investigated or have you ever been sanctioned, reprimanded, or cautioned by a military hospital, facility, or agency, or voluntarily terminated or resigned while under investigation or in exchange for no investigation by a hospital or healthcare facility of any military agency?
Has your professional liability coverage ever been cancelled, restricted, declined or not renewed by the carrier based on your individual liability history?
Have you ever been assessed a surcharge, or rated in a high-risk class for your specialty, by your professional liability insurance carrier, based upon your individual liability history?
Have you ever had professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years?
Have you ever been convicted of, pled guilty to, or pled nolo contender to any felony?
In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offence or sexual misconduct?
Have you ever been court-martialed for actions related to your duties as a medical professional?
Are you currently engaged in the illegal use of drugs? ("Currently" means sufficiently recent to justify a reasonable belief that the use of drug may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs" refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. 812.22. It "does not include the use of a drug taken under supervision by a licensed health care professional, or other uses authorized by the controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription controlled substances.)
Do you use any chemical substances that would in any way impair or limit your ability to practice medicine and perform the functions of your job with reasonable skill and safety?
Do you have any reason to believe that you would pose a risk to the safety or well-being of your patients?
Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation?

Maximum file size: 10.49MB

Supporting Documents

As part of your application, you are required to submit the following supporting documents:

  • State License(s) (If psychiatrist, must include DEA and CDS licenses)
  • Face Sheet of Professional Liability Insurance (include CAT Fund information if applicable)
  • Current Professional Curriculum Vitae / Resume
  • Completed IRS Form W-9
  • When applicable, include Educational Commission for Foreign Medical Graduates Certificate
Would you like to attach your required supporting documents to this disclosure statement?

Maximum file size: 10.49MB

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