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United Behavioral Health Addendum to the State of Texas Standardized Physician Credentialing <strong>Application</strong> 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 <strong>com</strong>plete an ACGME approved psychiatry residency? __ Yes __ No @UBH/USBHPC/LEI 6/2004 Page 2
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 @UBH/USBHPC/LEI 6/2004 Page 3
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