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 firstname.lastname@example.org.