Mail Completed Application To - Ubhonline.com

Mail completed application to: 

United Behavioral HealthCare 

Network Development 

2000 West Loop South, Ste. 900 

Houston, Texas 77027 

Please complete the attached addendum required and submit with the Texas Standardized Credentialing 

application to UBH. The following documents are required: 

! Completed, signed and dated Texas Standardized Credentialing Application. 

! Substitute W-9 Form or W-9 Form must be signed and dated (the form may be signed by the Clinician or 

the controller of the tax identification number). You must attach a separate W-9 form for each tax 

identification number used. 

! A photocopy of current State License(s)/State Certification(s) with expiration date(s). 

! A photocopy of current Professional Liability Insurance Policy indicating limits of coverage and an 

expiration date (Clinician must be named as the insured on the policy or an attached letter showing the 

names of all clinicians covered under the policy). UBH requires $1million/$3 million coverage for 

physicians and $1million/$1 million for non-physician Clinicians. If your state has a mandatory patient 

compensation fund, you must include proof of participation in this program. You must submit professional 

liability insurance policies that provide coverage at all practices (may require more than one policy). 

! A photocopy of the ECFMG Certification (foreign medical school graduates only). 

! A photocopy of the current Federal Drug Enforcement Agency (DEA) Registration and State 

Controlled Substance Permit, if applicable. 

*PLEASE NOTE: Incomplete applications or missing documents delay the credentialing process. If any 

information on the application is missing or incomplete, the application will be returned. 

@UBH/USBHPC/LEI 6/2004 Page 1

United Behavioral Health Addendum to the State of Texas Standardized Physician 

Credentialing Application 

Instructions: Please type or print legibly. Respond to all questions indicating N/A when the question 

does not apply. Attach additional pages where necessary, labeling with the corresponding question. 

I. Personal Information 

Last Name First Name Middle Name Previous Surname 

Social Security Number Date of Birth Gender Degree 

Medicare Billing Number Medicaid Billing Number UPIN NPI 

City State Zip Email Address 

Have you signed a Medicare Opt-Out Agreement? ___ No ___ Yes If yes, Date 

Please list all languages in which you conduct treatment: 

Are you fluent in American Sign Language? ___ Yes ___ No 

Optional – Please list your Race (used to meet patient referral requests) 

____ White ____ Black or African 

____ Hispanic 

American 

____ American Indian or 

Alaska Native 

____ Asian ____ Native Hawaiian or 

Pacific Islander 

____ Other ___________________________________________ 

II. Please describe your coverage arrangements for patient emergencies 24 hours per 

day, seven days a week. (Advising patients to call 911 is not sufficient.) 

III. Physicians 

Did you successfully complete an ACGME approved psychiatry residency? __ Yes __ No 


IV. Areas of Clinical Expertise - Please check all areas you have clinical training and experience AND 

are currently willing to treat in your practice. (Please note that all clinicians are assigned depression, 

anxiety, and mood disorders.) 

___ Abuse (Physical, Sexual, etc) 

___ Adoption Issues 

___ Attention Deficit Disorders (ADHD) 

___ Bariatric/Gastric Bypass Evaluation 

___ Behavior Modification 

___ Biofeedback 

___ Certified Pastoral Counselor 

___ Christian Counseling 

___ Cognitive Behavioral Therapy 

___ Compulsive Gambling 

___ Crisis Diversionary Services 

___ Developmental Disabilities 

___ Dialectical Behavioral Therapy 

___ Dissociative Disorders 

___ Domestic Violence 

___ Electro-Convulsive Therapy (ECT) 

___ Forensic 

___ Gay/Lesbian Issues 

___ Gay/Lesbian Identified Clinician 

___ Grief/Bereavement 

___ Hearing Impaired Populations 

___ HIV/AIDS/ARC 

___ Home Care/Home Nursing Visits 

___ Hypnosis 

___ Independent/Qualified Medical Examiner 

___ Infertility 

___ Learning Disabilities 

___ Medical Illness/Disease Management 

___ Obsessive Compulsive Disorder 

___ Organic Disorders 

___ Pain Management 

___ Personality Disorders 

___ Phobia 

___ Police/Fire Fighters 

___ Post Traumatic Stress Disorder 

___ Psych Testing 

___ Psychotic/Schizophrenic Disorders 

___ Rape Issues 

___ Sex Offender Treatment 

___ Sexual Dysfunction 

___ Sleep Disorders 

___ Somatoform Disorders 

Populations Treated: 

___ Couples/Marriage Therapy 

___ Family Therapy 

___ Group Therapy 

___ Inpatient Therapy 

___ Adult 


SPECIALTY ATTESTATION 

NOTE: UBH/USBHPC/LEI requires additional training and/or experience for the following 

populations, professionals, and specialties. (Please see attached Specialty Requirements.) 

Clinician Name 

Degree 

Phone 

I have reviewed the UBH/USBHPC/LEI specialty requirements criteria that a Clinician must 

meet to be considered a specialist in the following treatment areas. After reviewing the 

criteria, I hereby attest that by placing a check next to a specialty or specialties, I meet 

UBH/USBHPC/LEI’s requirements for that treatment area. 

___ Preschool (0-5 years) 

___ Children (6-12 years) 

___ Adolescents (13-18 years) 

___ Geriatrics 

___ Chemical Dependency/Substance Abuse 

___ Certified Employee Assistance Professional (CEAP) 

___ Critical Incident Stress Debriefing 

___ Disability Evaluation/Management 

___ Employee Assistance Professional (*submit UBH/USBHPC/LEI/LEI EAP questionnaire) 

___ Eating Disorders 

___ Pervasive Development Disorder 

___ Substance Abuse Professional (*DOT approved certification) 

___ Worker’s Compensation 

___ Neuropsychological Testing 

___ Nurses – Prescriptive Privileges (attach requirements - see page 7) 

I understand that UBH/USBHPC/LEI may require documentation to verify that I meet the 

criteria outlined under Specialty Requirements pertaining to the specialty or specialties I have 

designated above. I will cooperate with a UBH/USBHPC/LEI documentation audit, if 

requested, to verify that I meet the required criteria. 

I hereby attest that all of the information above is true and accurate to the best of my 

knowledge. I understand that any information provided pursuant to this attestation that is 

subsequently found to be untrue and/or incorrect could result in my termination from the 

UBH/USBHPC/LEI network. 

Please note that standard credentialing criteria must be met before specialty designation can be considered. 

Printed Name of Applicant: 

Original Signature of Applicant: 

(Must be an original signature – not copied or stamped) 

Date: 


PHYSICIAN SPECIALTY REQUIREMENTS 

(Must sign "Specialty Attestation” attached) 

PRESCHOOL/CHILDREN: 

♦ Completion of an ACGME approved Child Fellowship OR 

♦ Recognized certification in Child Psychiatry 

AND 1 of the following: 

♦ 10 hours of CME in preschool/children in the last 24 month period 

♦ Evidence of at least 25% of practice experience in the treatment of preschool/children 

ADOLESCENTS: 

♦ Completion of an ACGME approved Child and Adolescent Fellowship OR 

♦ Recognized certification in Adolescent Psychiatry 


♦ 10 hours of CME in adolescents in the last 24 month period 

♦ Evidence of at least 25% of practice experience in treating adolescent patients 

GERIATRICS: 

♦ Completion of an ACGME approved Geriatric Fellowship OR 

♦ Recognized certification in Geriatric Psychiatry 


♦ 10 hours of CME in Geriatrics in the last 24 month period 

♦ Evidence of 25% of practice experience in treating geriatric patients 

CHEMICAL DEPENDENCY/SUBSTANCE ABUSE: 

♦ Completion of an ACGME approved fellowship in Addiction Medicine OR 

♦ Certification in Addiction Medicine or ASAM 


♦ 10 hours of CME in Substance Abuse in the last 24month period 

♦ Evidence of 25% of practice experience in substance abuse 

DISABILITY: 

♦ 

♦ 

Documentation of specialized training in the provision of disability evaluation and treatment. 

Annual CME credits in the evaluation and management of disability patients. 

EATING DISORDERS: 

♦ One year fellowship, internship or practice in Eating Disorders, completed at an accredited institution or approved program 

AND 

♦ Evidence of at least one year professional experience with at least 25% of practice in the treatment of eating disorders 

♦ 10 hours CME in Eating Disorders in the last 24 month period 

PERVASIVE DEVELOPMENTAL DISORDER: 

♦ 

♦ 

6 months full-time clinical work in a PDD clinic or structured PDD 

setting within past 5 years 

OR 

20% of current practice involved in the assessment and treatment of patients with PDD 

WORKER’S COMPENSATION: 

♦ 

24 months experience assessing and treating worker’s compensation cases. 


PSYCHOLOGISTS & MASTER’S LEVEL CLINICIANS SPECIALTY REQUIREMENTS 

(Must sign "Specialty Attestation” attached) 

PRESCHOOL/CHILDREN: 

♦ Completion of an APA approved or other accepted training 

program in Child Psychology 


♦ 10 hours of CEU in preschool/children in the last 24 month period 

♦ Evidence of at least 25% of practice experience in the treatment 

of preschool/children 

ADOLESCENTS: 


program in Adolescent Psychology 


♦ 10 hours of CEU in adolescents in the last 24 month period 

♦ Evidence of at least 25% of practice experience in treating 

adolescent patients 

GERIATRICS: 


program in Geriatric Psychology 


♦ 10 hours of CEU in Geriatrics/Gerontology in the last 24 month 

period 

♦ Evidence of 25% of practice experience in treating geriatric 

patients 

CHEMICAL DEPENDENCY/SUBSTANCE ABUSE: 

♦ Complete an APA or other accepted training in Addictionology 

OR 

♦ Certification in Addiction Counseling 


♦ 10 hours of CEU in Substance Abuse in the last 24 month period 

♦ Evidence of 25% practice experience in substance abuse 

CERTIFIED EMPLOYEE ASSISTANCE PROFESSIONAL (CEAP): 

♦ 

Certificate from the Employee Assistance Certification 

Commission 

CRITICAL INCIDENT STRESS DEBRIEFING: 

♦ 

♦ 

Certificate of CISD training from American Red Cross or Mitchell 

model 

Documentation of training and CEU units in the provision of CISD 

services. 

NEUROPSYCHOLOGICAL TESTING – Psychologist Only 

♦ 

♦ 

♦ 

♦ 

DISABILITY: 

♦ 

♦ 

Documentation of specialized training in the provision of disability 

evaluation and treatment. 

10 hours CEU in the evaluation and management of disability 

patients in the last 24 month period 

EMPLOYEE ASSISTANCE PROFESSIONAL (EAP): 

♦ 

♦ 

♦ 

Must pass UBH/USBHPC/LEI EAP questionnaire, and 

Minimum of two years experience in the delivery of EAP core 

technology as defined by EAPA, and 

Minimum of one annual training (CEU credits or professional 

development hours) in any of the six EAP content areas 

EATING DISORDERS: 

♦ One year fellowship, internship or practice in Eating Disorders, 

completed at an accredited institution or approved program 

AND 

♦ Evidence of at least one-year professional experience with at 

least 25% of practice in the treatment of eating disorders 

♦ 10 hours of CEU in Eating Disorders in the last 24 month period 

PERVASIVE DEVELOPMENTAL DISORDER: 

♦ 

♦ 

6 months full-time clinical work in a PDD clinic or structured PDD 

setting within past 5 years 

OR 

20% of current practice involved in the assessment and treatment 

of patients with PDD 

SUBSTANCE ABUSE PROFESSIONAL: 

♦ 

Certificate of training in federal Department of Transportation 

SAP functions and regulatory requirements (agencies providing 

such certification include, but not limited to, Blair and Burke, 

EAPA and NMDAC). 

WORKER’S COMPENSATION: 

♦ 

24 months experience assessing and treating worker’s 

compensation cases. 

Member of the American Board of Clinical Neuropsychology OR the American Board of Professional Neuropsychology 

OR 

Completion of courses in Neuropsychology including: Neuroanatomy, Neuropsychological testing, Neuropathology, or Neuropharmacology 

Completion of an internship, fellowship, or practicum in Neuropsychological Assessment at an accredited institution 

AND 

Two years of supervised professional experience in Neuropsychological Assessment. 

NURSES - Please submit a copy of your ANCC certification in behavioral health nursing (adult or 

child/adolescent mental health), if required by your state to practice independently. Certification 

is required for your participation on the UBH panel in states requiring ANCC. 

Are you specifically requesting prescriptive privileges? __ Yes __ No 

For PRESCRIPTIVE AUTHORITY you must: 

♦ 

♦ 

♦ 

♦ 

♦ 

Possess a currently valid license as a Registered Nurse in the state(s) in which you practice 

Be authorized for prescriptive authority in the state in which you practice 

Meet state specific mandates for the state in which you practice regarding DEA license and physician supervision 

Attest that you meet your state’s collaborative or supervisory agreement requirements 

Specifically request prescriptive privileges on the UBH/USBHPC/LEI application above 


IMPORTANT TAX DOCUMENT 

SUBSTITUTE FORM W-9 

Request for Taxpayer Identification Number 

As part of the contracting process, we are requesting that you complete this Substitute Form W-9 for each TIN. 

We are required by law to obtain this information from you when making a reportable payment to you. If you do 

not provide us with this information, your payments may be subject to 31% federal income tax backup 

withholding. Also, if you do not provide us with this information, you may be subject to a $50 penalty imposed 

by the Internal Revenue Service under Section 6723 of the Internal Revenue Code. 

This information must be consistent with the data provided on Page 2 of the application (Office 

information). 

1. Taxpayer Name 

(To whom the check is payable) 

Doing Business as: 

(A division name if a corporation or the 

name of the business if a sole proprietor) 

2. Taxpayer Address 

DBA 

(A legal entity name if a corporation or partnership) 

3. Taxpayer Identification Number 

a. Corporation 

b. Partnership 

c. Sole Proprietorship 

d. Tax Exempt Entity 

e. Other - Please Explain 

(List employer identification number) 


(List social security number or employer identification number) 


4. Effective Date of Taxpayer Name 

& TIN 

5. Form Completed By 

Print name) 

6. Signature 

(Signature) 

7. Today's Date 

8. Daytime Phone Number ( ) 

PLEASE NOTE: INFORMATION REPORTED ON LINES 1-3 MUST BE CONSISTENT WITH DATA ON FILE 

WITH THE IRS AND SOCIAL SECURITY ADMINISTRATION.

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