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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
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