Treatment Provider Application

  • Identifying Information

  • Address Information

    Please list all locations and group affiliations.
  • Primary Office
  • Work History

    Please attach a CV reflecting work history including month/year dates (required). Include a written explanation for any employment gaps greater than 6 months.
  • Accepted file types: doc, docx, pdf.
  • References

    List the names, complete addresses (including zip codes), and phone numbers of three professional references not in practice or affiliaited with you.
  • NameAddress, City, State & Zip CodeTelephone # 
    Add a new row
  • License History

    Please list licensure information for the past 10 years.
  • Type (i.e., State, CDS, DEA, etc.)StateLicense Type (i.e., MD, LPC, etc.)NumberIssue/Renewal DateExpiration Date 
    Add a new row
  • Experience

    (select all that applies)
  • Specialty Certifications

  • If you selected Yes, please list below and attach a copy of any certificate(s).
  • Certification BoardSpecialtyCertification NumberIssue/Renewal DateExpiration Date 
    Add a new row
  • Accepted file types: doc, docx, pdf.
  • Professional Liability Insurance

  • Languages

    Do you speak a language other than English? If so, please list them below.
  • Add a new row
  • Specialty Services

    Please check all that apply.
  • Client Groups

    Please check all that apply.
  • Clinical Support Information

    This information is required to process application.

  • Please answer the following questions if you checked Disability Management/Workers Compensation as a specialty.
  • Specialty/Treatment Categories

    Please check all that apply.
  • Presenting Problems

    Please check the disorders you treat most frequently.
  • Add a new row
    Please list any other disorders you treat that aren't covered in the list above.
  • What disorders/clinical areas do you not treat?

    Please list any disorders/clinical areas that you do not treat below.
  • Add a new row
    Please list any other disorders you treat that aren't covered in the list above.
  • Availability

  • Mandatory Questionnaire

    IMPORTANT: If any of the following questions is answered "Yes", please provide a summary below or attach an explanation for each answer. If any questions do not apply to you, please answer "no". Failure to respond or provide explanations for "Yes" responses may result in a delay of application processing.
  • Licensure Information
    In the last ten (10) years:

  • Insurance Information
    In the last ten (10) years:

  • Hospital and Other Affiliations
    In the last ten (10) years:

  • Health Status
    In the last ten (10) years:

  • Criminal History
    In the last ten (10) years:

  • Comments
  • Signature Area

  • This field is for validation purposes and should be left unchanged.