Behavioral Health Providers Form

If you are interested in participating in our network, we will need some additional information first. Please complete the information on the next screen and our provider recruitment team will reach out to you shortly.

We’ll use the information you provide to contact you. You are now being transferred to the pre-credentialing form.

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Do you have a valid license to practice?
Yes No

Are you authorized to work in the United States or Puerto Rico?
Yes No

Have you ever had a malpractice claim that resulted in any payment or any form of ruling against you?
Yes No

Have you ever been convicted of a felony?
Yes No

Have you had your license or privileges revoked from any facility or health plan for any reason?
Yes No

Please attach a government-issued Photo ID. We accept .jpg, .jpeg, .png, .pdf files only.

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Expiration Date *

To help us get to know you better, please upload your Resume/CV here. We accept PDF, .doc and .docx files only.

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