State Of MN Addendum - Ubhonline.com
State Of MN Addendum - Ubhonline.com
State Of MN Addendum - Ubhonline.com
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United Behavioral Health <strong>Addendum</strong> to the <strong>State</strong> of Minnesota Standardized<br />
Credentialing Application<br />
Instructions: Please type or print legibly. Respond to all questions indicating N/A when the question<br />
does not apply. Attach additional pages where necessary, labeling with the corresponding question.<br />
I. Personal Information<br />
Last Name First Name Middle Name Previous Surname<br />
Social Security Number Date of Birth Gender Degree<br />
Medicare Billing Number Medicaid Billing Number UPIN NPI<br />
City <strong>State</strong> Zip Email Address<br />
Have you signed a Medicare Opt-Out Agreement? ___ No ___ Yes If yes, Date<br />
Please list all languages in which you conduct treatment:<br />
Are you fluent in American Sign Language? ___ Yes ___ No<br />
Optional – Please list your Race (used to meet patient referral requests)<br />
____ White ____ Black or African<br />
____ Hispanic<br />
American<br />
____ American Indian or<br />
Alaska Native<br />
____ Asian ____ Native Hawaiian or<br />
Pacific Islander<br />
____ Other ___________________________________________<br />
II. Please describe your coverage arrangements for patient emergencies 24 hours per<br />
day, seven days a week. (Advising patients to call 911 is not sufficient.)<br />
III. Physicians<br />
Did you successfully <strong>com</strong>plete an ACGME approved psychiatry residency? __ Yes __ No<br />
@UBH/USBHPC/LEI 6/2004 Page 1
IV. Areas of Clinical Expertise - Please check all areas you have clinical training and experience AND<br />
are currently willing to treat in your practice. (Please note that all clinicians are assigned depression,<br />
anxiety, and mood disorders.)<br />
___ Abuse (Physical, Sexual, etc)<br />
___ Adoption Issues<br />
___ Attention Deficit Disorders (ADHD)<br />
___ Bariatric/Gastric Bypass Evaluation<br />
___ Behavior Modification<br />
___ Biofeedback<br />
___ Certified Pastoral Counselor<br />
___ Christian Counseling<br />
___ Cognitive Behavioral Therapy<br />
___ Compulsive Gambling<br />
___ Crisis Diversionary Services<br />
___ Developmental Disabilities<br />
___ Dialectical Behavioral Therapy<br />
___ Dissociative Disorders<br />
___ Domestic Violence<br />
___ Electro-Convulsive Therapy (ECT)<br />
___ Forensic<br />
___ Gay/Lesbian Issues<br />
___ Gay/Lesbian Identified Clinician<br />
___ Grief/Bereavement<br />
___ Hearing Impaired Populations<br />
___ HIV/AIDS/ARC<br />
___ Home Care/Home Nursing Visits<br />
___ Hypnosis<br />
___ Independent/Qualified Medical Examiner<br />
___ Infertility<br />
___ Learning Disabilities<br />
___ Medical Illness/Disease Management<br />
___ Obsessive Compulsive Disorder<br />
___ Organic Disorders<br />
___ Pain Management<br />
___ Personality Disorders<br />
___ Phobia<br />
___ Police/Fire Fighters<br />
___ Post Traumatic Stress Disorder<br />
___ Psych Testing<br />
___ Psychotic/Schizophrenic Disorders<br />
___ Rape Issues<br />
___ Sex <strong>Of</strong>fender Treatment<br />
___ Sexual Dysfunction<br />
___ Sleep Disorders<br />
___ Somatoform Disorders<br />
Populations Treated:<br />
___ Couples/Marriage Therapy<br />
___ Family Therapy<br />
___ Group Therapy<br />
___ Inpatient Therapy<br />
___ Adult<br />
@UBH/USBHPC/LEI 6/2004 Page 2
SPECIALTY ATTESTATION<br />
NOTE: UBH/USBHPC/LEI requires additional training and/or experience for the following<br />
populations, professionals, and specialties. (Please see attached Specialty Requirements.)<br />
Clinician Name<br />
Degree<br />
Phone<br />
I have reviewed the UBH/USBHPC/LEI specialty requirements criteria that a Clinician must<br />
meet to be considered a specialist in the following treatment areas. After reviewing the<br />
criteria, I hereby attest that by placing a check next to a specialty or specialties, I meet<br />
UBH/USBHPC/LEI’s requirements for that treatment area.<br />
___ Preschool (0-5 years)<br />
___ Children (6-12 years)<br />
___ Adolescents (13-18 years)<br />
___ Geriatrics<br />
___ Chemical Dependency/Substance Abuse<br />
___ Certified Employee Assistance Professional (CEAP)<br />
___ Critical Incident Stress Debriefing<br />
___ Disability Evaluation/Management<br />
___ Employee Assistance Professional (*submit UBH/USBHPC/LEI/LEI EAP questionnaire)<br />
___ Eating Disorders<br />
___ Pervasive Development Disorder<br />
___ Substance Abuse Professional (*DOT approved certification)<br />
___ Worker’s Compensation<br />
___ Neuropsychological Testing<br />
___ Nurses – Prescriptive Privileges (attach requirements - see page 7)<br />
I understand that UBH/USBHPC/LEI may require documentation to verify that I meet the<br />
criteria outlined under Specialty Requirements pertaining to the specialty or specialties I have<br />
designated above. I will cooperate with a UBH/USBHPC/LEI documentation audit, if<br />
requested, to verify that I meet the required criteria.<br />
I hereby attest that all of the information above is true and accurate to the best of my<br />
knowledge. I understand that any information provided pursuant to this attestation that is<br />
subsequently found to be untrue and/or incorrect could result in my termination from the<br />
UBH/USBHPC/LEI network.<br />
Please note that standard credentialing criteria must be met before specialty designation can be considered.<br />
Printed Name of Applicant:<br />
Original Signature of Applicant:<br />
(Must be an original signature – not copied or stamped)<br />
Date:<br />
@UBH/USBHPC/LEI 6/2004 Page 3
PHYSICIAN SPECIALTY REQUIREMENTS<br />
(Must sign "Specialty Attestation” attached)<br />
PRESCHOOL/CHILDREN:<br />
♦ Completion of an ACGME approved Child Fellowship OR<br />
♦ Recognized certification in Child Psychiatry<br />
AND 1 of the following:<br />
♦ 10 hours of CME in preschool/children in the last 24 month period<br />
♦ Evidence of at least 25% of practice experience in the treatment of preschool/children<br />
ADOLESCENTS:<br />
♦ Completion of an ACGME approved Child and Adolescent Fellowship OR<br />
♦ Recognized certification in Adolescent Psychiatry<br />
AND 1 of the following:<br />
♦ 10 hours of CME in adolescents in the last 24 month period<br />
♦ Evidence of at least 25% of practice experience in treating adolescent patients<br />
GERIATRICS:<br />
♦ Completion of an ACGME approved Geriatric Fellowship OR<br />
♦ Recognized certification in Geriatric Psychiatry<br />
AND 1 of the following:<br />
♦ 10 hours of CME in Geriatrics in the last 24 month period<br />
♦ Evidence of 25% of practice experience in treating geriatric patients<br />
CHEMICAL DEPENDENCY/SUBSTANCE ABUSE:<br />
♦ Completion of an ACGME approved fellowship in Addiction Medicine OR<br />
♦ Certification in Addiction Medicine or ASAM<br />
AND 1 of the following:<br />
♦ 10 hours of CME in Substance Abuse in the last 24month period<br />
♦ Evidence of 25% of practice experience in substance abuse<br />
DISABILITY:<br />
♦<br />
♦<br />
Documentation of specialized training in the provision of disability evaluation and treatment.<br />
Annual CME credits in the evaluation and management of disability patients.<br />
EATING DISORDERS:<br />
♦ One year fellowship, internship or practice in Eating Disorders, <strong>com</strong>pleted at an accredited institution or approved program<br />
AND<br />
♦ Evidence of at least one year professional experience with at least 25% of practice in the treatment of eating disorders<br />
♦ 10 hours CME in Eating Disorders in the last 24 month period<br />
PERVASIVE DEVELOPMENTAL DISORDER:<br />
♦<br />
♦<br />
6 months full-time clinical work in a PDD clinic or structured PDD<br />
setting within past 5 years<br />
OR<br />
20% of current practice involved in the assessment and treatment of patients with PDD<br />
WORKER’S COMPENSATION:<br />
♦<br />
24 months experience assessing and treating worker’s <strong>com</strong>pensation cases.<br />
@UBH/USBHPC/LEI 6/2004 Page 4
PSYCHOLOGISTS & MASTER’S LEVEL CLINICIANS SPECIALTY REQUIREMENTS<br />
(Must sign "Specialty Attestation” attached)<br />
PRESCHOOL/CHILDREN:<br />
♦ Completion of an APA approved or other accepted training<br />
program in Child Psychology<br />
AND 1 of the following:<br />
♦ 10 hours of CEU in preschool/children in the last 24 month period<br />
♦ Evidence of at least 25% of practice experience in the treatment<br />
of preschool/children<br />
ADOLESCENTS:<br />
♦ Completion of an APA approved or other accepted training<br />
program in Adolescent Psychology<br />
AND 1 of the following:<br />
♦ 10 hours of CEU in adolescents in the last 24 month period<br />
♦ Evidence of at least 25% of practice experience in treating<br />
adolescent patients<br />
GERIATRICS:<br />
♦ Completion of an APA approved or other accepted training<br />
program in Geriatric Psychology<br />
AND 1 of the following:<br />
♦ 10 hours of CEU in Geriatrics/Gerontology in the last 24 month<br />
period<br />
♦ Evidence of 25% of practice experience in treating geriatric<br />
patients<br />
CHEMICAL DEPENDENCY/SUBSTANCE ABUSE:<br />
♦ Complete an APA or other accepted training in Addictionology<br />
OR<br />
♦ Certification in Addiction Counseling<br />
AND 1 of the following:<br />
♦ 10 hours of CEU in Substance Abuse in the last 24 month period<br />
♦ Evidence of 25% practice experience in substance abuse<br />
CERTIFIED EMPLOYEE ASSISTANCE PROFESSIONAL (CEAP):<br />
♦<br />
Certificate from the Employee Assistance Certification<br />
Commission<br />
CRITICAL INCIDENT STRESS DEBRIEFING:<br />
♦<br />
♦<br />
Certificate of CISD training from American Red Cross or Mitchell<br />
model<br />
Documentation of training and CEU units in the provision of CISD<br />
services.<br />
NEUROPSYCHOLOGICAL TESTING – Psychologist Only<br />
♦<br />
♦<br />
♦<br />
♦<br />
DISABILITY:<br />
♦<br />
♦<br />
Documentation of specialized training in the provision of disability<br />
evaluation and treatment.<br />
10 hours CEU in the evaluation and management of disability<br />
patients in the last 24 month period<br />
EMPLOYEE ASSISTANCE PROFESSIONAL (EAP):<br />
♦<br />
♦<br />
♦<br />
Must pass UBH/USBHPC/LEI EAP questionnaire, and<br />
Minimum of two years experience in the delivery of EAP core<br />
technology as defined by EAPA, and<br />
Minimum of one annual training (CEU credits or professional<br />
development hours) in any of the six EAP content areas<br />
EATING DISORDERS:<br />
♦ One year fellowship, internship or practice in Eating Disorders,<br />
<strong>com</strong>pleted at an accredited institution or approved program<br />
AND<br />
♦ Evidence of at least one-year professional experience with at<br />
least 25% of practice in the treatment of eating disorders<br />
♦ 10 hours of CEU in Eating Disorders in the last 24 month period<br />
PERVASIVE DEVELOPMENTAL DISORDER:<br />
♦<br />
♦<br />
6 months full-time clinical work in a PDD clinic or structured PDD<br />
setting within past 5 years<br />
OR<br />
20% of current practice involved in the assessment and treatment<br />
of patients with PDD<br />
SUBSTANCE ABUSE PROFESSIONAL:<br />
♦<br />
Certificate of training in federal Department of Transportation<br />
SAP functions and regulatory requirements (agencies providing<br />
such certification include, but not limited to, Blair and Burke,<br />
EAPA and NMDAC).<br />
WORKER’S COMPENSATION:<br />
♦<br />
24 months experience assessing and treating worker’s<br />
<strong>com</strong>pensation cases.<br />
Member of the American Board of Clinical Neuropsychology OR the American Board of Professional Neuropsychology<br />
OR<br />
Completion of courses in Neuropsychology including: Neuroanatomy, Neuropsychological testing, Neuropathology, or Neuropharmacology<br />
Completion of an internship, fellowship, or practicum in Neuropsychological Assessment at an accredited institution<br />
AND<br />
Two years of supervised professional experience in Neuropsychological Assessment.<br />
NURSES - Please submit a copy of your ANCC certification in behavioral health nursing (adult or<br />
child/adolescent mental health), if required by your state to practice independently. Certification<br />
is required for your participation on the UBH panel in states requiring ANCC.<br />
Are you specifically requesting prescriptive privileges? __ Yes __ No<br />
For PRESCRIPTIVE AUTHORITY you must:<br />
♦<br />
♦<br />
♦<br />
♦<br />
♦<br />
Possess a currently valid license as a Registered Nurse in the state(s) in which you practice<br />
Be authorized for prescriptive authority in the state in which you practice<br />
Meet state specific mandates for the state in which you practice regarding DEA license and physician supervision<br />
Attest that you meet your state’s collaborative or supervisory agreement requirements<br />
Specifically request prescriptive privileges on the UBH/USBHPC/LEI application above<br />
@UBH/USBHPC/LEI 6/2004 Page 5
IMPORTANT TAX DOCUMENT<br />
SUBSTITUTE FORM W-9<br />
Request for Taxpayer Identification Number<br />
As part of the contracting process, we are requesting that you <strong>com</strong>plete this Substitute Form W-9 for each TIN.<br />
We are required by law to obtain this information from you when making a reportable payment to you. If you do<br />
not provide us with this information, your payments may be subject to 31% federal in<strong>com</strong>e tax backup<br />
withholding. Also, if you do not provide us with this information, you may be subject to a $50 penalty imposed<br />
by the Internal Revenue Service under Section 6723 of the Internal Revenue Code.<br />
This information must be consistent with the data provided on Page 2 of the application (<strong>Of</strong>fice<br />
information).<br />
1. Taxpayer Name<br />
(To whom the check is payable)<br />
Doing Business as:<br />
(A division name if a corporation or the<br />
name of the business if a sole proprietor)<br />
2. Taxpayer Address<br />
DBA<br />
(A legal entity name if a corporation or partnership)<br />
3. Taxpayer Identification Number<br />
a. Corporation<br />
b. Partnership<br />
c. Sole Proprietorship<br />
d. Tax Exempt Entity<br />
e. Other - Please Explain<br />
(List employer identification number)<br />
(List employer identification number)<br />
(List social security number or employer identification number)<br />
(List employer identification number)<br />
4. Effective Date of Taxpayer Name<br />
& TIN<br />
5. Form Completed By<br />
Print name)<br />
6. Signature<br />
(Signature)<br />
7. Today's Date<br />
8. Daytime Phone Number ( )<br />
PLEASE NOTE: INFORMATION REPORTED ON LINES 1-3 MUST BE CONSISTENT WITH DATA ON FILE<br />
WITH THE IRS AND SOCIAL SECURITY ADMINISTRATION.<br />
@UBH/USBHPC/LEI 6/2004 Page 6