Empathia Provider Application

(1)

Revised 9/24/2015 Empathia Provider Application Page 1

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

.

P

ROVIDER

I

NFORMATION

First Name: Middle Name: Last Name:

National Provider ID#: Date of Birth: Gender:



M



F

Years Post-Master’s Clinical Experience:

L

ICENSURE (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:

C

ERTIFICATIONS (Please Include Copies) Alcohol & Drug Certification:



State



National

State: ____________________ Type: ____________________ Lic/Cert #: _________________________ Year: ____________________ Expiration: ________________

A

DDITIONAL

C

ERTIFICATIONS (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:

O

FFICE

I

NFORMATION (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

(2)

A

DDITIONAL

O

FFICE

A

TTRIBUTES

1. This office is wheelchair accessible.



Y



N

2. This office is close to public transportation.



Y



N

3. This office is located in a home.



Y



N

C

URRENT

P

ROFESSIONAL

L

IABILITY

I

NSURANCE

I

NFORMATION

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?



Yes



No If yes, the name of the compensation fund:

P

REVIOUS

5 Y

EARS

P

ROFESSIONAL

L

IABILITY

I

NSURANCE

I

NFORMATION

IF

DIFFERENT

FROM

ABOVE

*

R

EQUIRED

*

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:

E

DUCATION AND

T

RAINING

Highest Degree Attained: Year Degree Awarded:

Graduate School:

Address: City/State/ZIP:

P

RACTICE

O

VERVIEW

Practice Description (Please enter up to 50 words describing your practice):

Do you work in a clinical practice for a minimum of ten hours per week?



Y



N

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?



Y



N

Are you able to return client phone calls within 1 business day?



Y



N

Are you able to offer a routine appointment within 3 business days?



Y



N

Are you able to offer an urgent appointment within 1 business day?



Y



N

How would you rate your overall familiarity with local community resources?



Excellent



Good



Fair

P

ROFESSIONAL

M

EMBERSHIPS

(3)

I

NSURANCE

P

LAN

I

NFORMATION

Please list below the insurance plans you currently accept.

C

RISIS

R

ESPONSE

,

SAP

AND

T

RAINING

Q

UALIFICATIONS

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.



Y



N

Number of years of onsite Trauma Response Service

experience:

_________

Number of onsite Trauma Responses

within the past two years:

_________

Types of Trauma Response Services you have performed?



Natural Disaster



Suicide



Terrorism



Other_______________________



Robbery



Death of Employee



Downsizing Ability to be onsite to provide services

within 24-72 hours?



Y



N

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.



Y



N

Do you have experience providing

EAP training?



Y



N Are you able to provide EAP training?



Y



N

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

EAP

E

XPERIENCE

Are you a Certified Employee Assistance Professional (CEAP)?



Y



N (If yes, please include a copy of your certificate.)

CEAP Certificate #: Date of Issue: Expiration Date:

Are you an Employee Assistance Specialist – Clinical (EAS-C)?



Y



N (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: ___________________________



Y



N

I have experience providing employee assistance counseling.



Y



N

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.



Y



N

I am qualified to provide general assessments, short-term problem-resolution counseling, and/or referrals for:

Mental Health



Y



N

Relationships, Family & Children Within Family



Y



N

Alcohol/Drug Addiction



Y



N

I am experienced in identifying and resolving workplace problems that may be caused or exacerbated by an employee's personal or work life.



Y



N 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.



Y



N

I have knowledge and experience with assessing and managing high-risk situations (e.g., suicidal, homicidal, or self-injury).



Y



N Please list EAPs where you have been or for which you are providing services (include dates and length of services provided).

(4)

S

ESSION

F

ORMAT

(C

HECK ALL THAT APPLY

)



Individual



Couples



Family



Group



Online e-counseling



Telephonic



Video



Other _______________

T

REATMENT

A

PPROACH

(C

)



Biofeedback/Neurofeedback



Brief Therapy



CBT



EMDR



Family Systems



Group



Hypnosis



Psychodynamic



Psychoeducational



Rational Emotive Therapy



Solution Focused



Other: _______________

C

LIENT

D

EMOGRAPHICS

(C

HECK 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

L

ANGUAGES

S

POKEN

O

THER

T

HAN

E

NGLISH



American Sign Language



Cantonese



French



Japanese



Mandarin



Russian



Spanish



Other __________________

O

PTIONAL

,

V

OLUNTARY

,

AND

N

OT

R

EQUIRED

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?



Y



N



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?



Y



N



Bisexual



Gay



Transgender



Heterosexual

Are you willing to identify your military experience for clients requesting your background?



Y



N

If so, are you a Veteran?



Y



N

Are you willing to identify your ethnicity and/or nationality for clients requesting an EAP counselor with your specific background?



Y



N



African American



Arab American



Hispanic



Native 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

(5)

T

REATMENT

S

PECIALTIES

(C

)



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 ______________________

R

EFERENCES

(O

UTSIDE CURRENT PRACTICE

/A

T LEAST ONE REFERENCE FROM AN

EAP

PROFESSIONAL IS PREFERRED

)

Name & Title: Name & Title:

Agency: Agency:

Phone: Phone:

(6)

D

ISCLOSURE

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?



Y



N

2. Have you ever been charged or convicted of a felony in any state?



Y



N 3. Have you ever been investigated by any professional or licensure board, professional association, private payor, state or federal regulatory agency, or

other authority?



Y



N

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?



Y



N 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?



Y



N

6. Are you aware of any formal disciplinary or criminal charges pending against you?



Y



N 7. Are you aware of any complaints against you filed with any licensing, certification, or other regulatory body?



Y



N 7a. Has it ever been determined that you have operated outside the recognized boundaries of your professional competencies?



Y



N 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?



Y



N 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?



Y



N 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?



Y



N 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?



Y



N 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?



Y



N 12.Has a professional liability carrier ever denied, limited, not renewed or canceled your coverage?



Y



N 13.Are you now or have you ever been sanctioned or excluded from federal, state or local government programs?



Y



N 14.Have any malpractice suits, professional liability suits, arbitration or other proceedings ever been instituted against you?



Y



N

A

BILITY TO

P

ERFORM

E

SSENTIAL

J

OB

F

UNCTIONS

1. Are you able to perform the essential functions of a practitioner in your area of practice?



Y



N 2. Do you require accommodations in order to perform these functions?



Y



N

If yes, please explain:

3. Are you currently engaged in the illegal use or abuse of drugs or controlled substances?



Y



N 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?



Y



N If yes, please explain:

(7)

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