United Behavioral Health/US Behavioral Health ... - Ubhonline.com

United Behavioral Health/US Behavioral Health Plan, California, Inc.
Clinician 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 Email address
City State Zip
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. Primary Clinic/Office Information (Please list all practices and addresses where you will see
UBH/USBHPC patients. Individual UBH contracts are valid at all practice locations.)
Name of Group/Clinic/Office
Federal Tax Id Number for this practice
Address County Check name for this practice (for TIN above)
City State Zip Your start date at this practice
Daytime Phone Number Emergency/After Hours Phone Secure Fax Number (for patient info) Other Fax Number
Office Contact Name Office Contact Phone Number Office Contact Fax Number
Is this practice located
in your home?
___ Yes ___ No
Are you accepting new
patients at this location?
___ Yes ___ No
Do you follow HIPPA
guidelines for privacy?
___ Yes ___ No
Does this office meet
state fire and safety
codes?
___ Yes ___ No
Are you available for evening
appointments at this location?
___ Yes ___ No
Are restrooms available for
all patients at this location?
___ Yes ___ No
Can another clinician
access patient records in
case of an emergency?
___ Yes ___ No
Do you have emergency
procedures in place in case
of fire or natural disaster?
___Yes ___No
Are you available for
weekend appointments
at this location?
___ Yes ___ No
Do you have patient rights posted
in your waiting room?
___ Yes ___ No
Do you obtain and document
consent for treatment (for MDs this
includes consent for medications)?
___ Yes ___ No
To ensure patient confidentiality
are all medical records stored in
locked cabinets?
___ Yes ___ No
Is this location handicap/
wheelchair accessible?
___ Yes ___ No
Is this location accessible
via public transportation?
___ Yes ___ No
Do you have written material explaining
after-hours coverage? ___ Yes ___
No
Are you able to treat hearing impaired
or deaf patients in this location?
___ Yes ___ No
Can individual session content be heard
by other patients?
___ Yes ___ No
@UBH/USBHPC/LEI 6/2004 Page 1

III. Please describe your coverage arrangements for patient emergencies 24 hours per
day, seven days a week. (Advising patients to call 911 is not sufficient.)
IV. Billing Address (If different from Primary Clinic/Office Address above)
Name of Group/Clinic/Office Phone Number Billing Contact
Address County Billing Contact Phone Number
City State Zip
V. Additional Office Location (Please make copies of page 2 for additional locations)
Name of Group/Clinic/Office
Federal Tax Id Number for this practice
Address County Check name for this practice (for TIN above)
City State Zip Your start date at this practice
Daytime Phone Number Emergency/After Hours Phone Secure Fax Number (for patient info) Other Fax Number
Office Contact Name Office Contact Phone Number Office Contact Fax Number
Is this practice located
in your home?
___ Yes ___ No
Are you accepting new
patients at this location?
___ Yes ___ No
Do you follow HIPPA
guidelines for privacy?
___ Yes ___ No
Does this office meet
state fire and safety
codes?
___ Yes ___ No
Are you available for evening
appointments at this location?
___ Yes ___ No
Are restrooms available for
all patients at this location?
___ Yes ___ No
Can another clinician
access patient records in
case of an emergency?
___ Yes ___ No
Do you have emergency
procedures in place in case
of fire or natural disaster?
___Yes ___No
Are you available for
weekend appointments
at this location?
___ Yes ___ No
Do you have patient rights posted
in your waiting room?
___ Yes ___ No
Do you obtain and document
consent for treatment (for MDs this
includes consent for medications)?
___ Yes ___ No
To ensure patient confidentiality
are all medical records stored in
locked cabinets?
___ Yes ___ No
Is this location handicap/
wheelchair accessible?
___ Yes ___ No
Is this location accessible
via public transportation?
___ Yes ___ No
Do you have written material explaining
after-hours coverage? ___ Yes ___
No
Are you able to treat hearing impaired
or deaf patients in this location?
___ Yes ___ No
Can individual session content be heard
by other patients?
___ Yes ___ No
@UBH/USBHPC/LEI 6/2004 Page 2

VI. Current Hospital Admitting Privileges
Name of Hospital
Type of Privileges
Address City State Zip Phone
Name of Hospital
Type of Privileges
Address City State Zip Phone
Name of Hospital
Type of Privileges
Address City State Zip Phone
VII. Professional Liability Insurance (Clinician must be named as insured on the policy or attachment)
Name of Carrier
Policy Number
Address City State Zip
Coverage Limits (Occurrence/Aggregate)
__ Occurrence
__ Claims Made
Dates of Coverage
Years with Carrier
VIII. Work History – Please provide a chronological work history for the past 5 years including employment, selfemployment,
clinical practice, service as an independent contractor, and military service. It is not necessary to duplicate
education, internship, residency or fellowship information previously reported. Please explain any gaps in work history
greater than 6 months. A Curriculum Vita may not be substituted for completion of this section.
Current Practice/Employer Name (must match practice information on page 2) Start Date (MM/YYYY) End Date (MM/YYYY)
Present
City State Title or Professional Occupation
Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY)
City State Title or Professional Occupation
Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY)
City State Title or Professional Occupation
Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY)
City State Title or Professional Occupation
Previous Practice/Employer Name Start Date (MM/YYYY) End Date (MM/YYYY)
City State Title or Professional Occupation
Please provide an explanation for any gaps in work history greater than 6 months:
Gap Dates: __________________ Explanation: _________________________________________________________________
(MM/YYYY to MM/YYYY)
Gap Dates: __________________ Explanation: _________________________________________________________________
(MM/YYYY to MM/YYYY)
@UBH/USBHPC/LEI 6/2004 Page 3

IX. 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 Victims
___ 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
@UBH/USBHPC/LEI 6/2004 Page 4

Areas of Clinical Expertise Continued
__ 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
___ 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 5

SPECIALTY ATTESTATION
NOTE: UBH/USBHPC 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 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’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 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 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 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 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:
@UBH/USBHPC/LEI 6/2004 Page 6

PHYSICIAN SPECIALTY REQUIREMENTS
(Must sign "Specialty Attestation” page 5)
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
AND 1 of the following:
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
AND 1 of the following:
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
AND 1 of the following:
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.
@UBH/USBHPC/LEI 6/2004 Page 7

PSYCHOLOGISTS & MASTER’S LEVEL CLINICIANS SPECIALTY REQUIREMENTS
(Must sign "Specialty Attestation” page 5)
PRESCHOOL/CHILDREN:
Completion of an APA approved or other accepted training
program in Child Psychology
AND 1 of the following:
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:
Completion of an APA approved or other accepted training
program in Adolescent Psychology
AND 1 of the following:
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:
Completion of an APA approved or other accepted training
program in Geriatric Psychology
AND 1 of the following:
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
AND 1 of the following:
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
Submit a letter from the supervising physician attesting to the supervisory relationship (if state requirement)
Specifically request prescriptive privileges on the UBH/USBHPC application above and on page 9
@UBH/USBHPC/LEI 6/2004 Page 8

United Behavioral Health/USBHPC
Authorization and Release
I understand and acknowledge that I am applying for participation status with United Behavioral Health/US Behavioral Health
Plan, California, Inc. (UBH/USBHPC and that I am responsible for providing all information reasonably requested by
UBH/USBHPC.
I hereby certify that all information contained in this application and all its attachments is accurate, true
and complete. I certify that I have personally read and completed all disclosure questions. I
understand that I retain the right to review any information submitted to UBH/USBHPC in support of
credentialing my application.
I understand that it is my responsibility to promptly notify UBH/USBHPC of any changes or additions to the information
contained in the Application and that all the information provided during the application process is subject to UBH/USBHPCs
investigation and review. I understand and agree that if any information contained in this Application is determined to be
false or constitutes a material misstatement, my Application may be denied or my participation status may be involuntarily
terminated. I understand that in the event that my Application is denied or my participation status is terminated involuntarily,
UBH/USBHPC may be required to submit a report to the National Practitioner Data Bank and to state licensing authorities.
I understand I have the right to review information submitted to support my (re)credentialing application. I have the right to
correct erroneous information obtained by UBH/USBHPC to evaluate my (re)credentialing application. This does not include
references, recommendations, or other peer-review protected information. I must submit any corrections, in writing, within
10 days. I have the right to obtain information regarding the status of my application.
By applying for participation status, I hereby authorize UBH/USBHPC, its affiliates and successors, to obtain any information
that may be relevant to an evaluation of my professional qualifications, ability, and character to practice medicine, including
information about disciplinary actions or other confidential or privileged information, and other credentials. I hereby
authorize all individuals, institutions and entities with which I have been or am now associated, including but not limited to,
educational institutions, hospitals, clinics and health plans, professional liability carriers, licensing boards, specialty boards,
professional societies, government agencies, and any other pertinent sources, to provide any relevant information requested
by UBH/USBHPC or its representatives. I also consent to the inspection by representatives of UBH/USBHPC of all facilities
and/or documents that may be material to my request for participation status with UBH/USBHPC.
I hereby release from liability all individuals, institutions and entities and their respective agents from liability for all acts
performed in good faith and without malice in connection with the investigation and review of this Application, my
participation status with UBH/USBHPC and the release and exchange of information by such individuals, institutions and
entities. This release shall be in addition to any other applicable immunity provided by state and federal law. UBH/USBHPC
is bound by all state and federal confidentiality laws.
I understand and agree that the authorization and release given by me is irrevocable as long as I am an applicant for
participation status with UBH/USBHPC or am a participating Clinician with UBH/USBHPC. This authorization to obtain
confidential information about me remains in effect until I notify UBH/USBHPC otherwise, in writing, except as otherwise
provided under state law.
I further acknowledge that I have read and understand this Authorization and Release.
By signing this attestation, I acknowledge that I have hospital admitting privileges in good standing, if applicable.
I warrant that I have the authority to sign this Application, on my own behalf, and on behalf of any entity or organization for
which I am signing in a representative capacity. I understand that if this Application is accepted by UBH/USBHPC, I will be
bound by the terms of the UBH/USBHPC Clinician Agreement, of which this Application is a part. I have read and
understand the terms of the UBH/USBHPC Clinician Agreement, and agree to be bound by them, and accept the published
rates for my level of licensure.
A copy of this document shall have the same effect as the original.
Printed Name of Applicant:
Original Signature of Applicant:
Date:
@UBH/USBHPC/LEI 6/2004 Page 9

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 employer identification number)
(List social security number or employer identification number)
(List 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.
@UBH/USBHPC/LEI 6/2004 Page 10

@UBH/USBHPC/LEI 6/2004 Page 11