• NMCC-WACC Staff Annual Update

    Dear team member, please complete this form to help expedite the annual update and attestion process.

  • Staff Information

  • Has your address changed in the last 12 months?
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • BACKGROUND CHECK

  • Washington Area Clinical Center and the Maryland Department Health (MDH) are concerned about the health and safety of all individuals and the safeguarding of agency property.  All reasonable efforts will be made to provide a safe and secure environment for our patients, other team members, and their family members. Based on this objective, a criminal history record check. Please attest to the following information:

     

     

  • Have you ever been convicted or investigated of a crime or misdemeanor (other than minor traffic violations)?*
  • Have you ever been party to a malpractice action or had a malpractice action brought against you?*
  • Have you ever been terminated from or resigned from a clinical or professional training program?*
  • Have you ever been censured or found guilty of any unethical practices by a state or private license, certification board, or a professional organization of which you were a member?*
  • Have you ever been terminated or asked to resign from employment since obtaining your (professional) license?*
  • Do you grant NMCC-WACC permission to conduct a background check?*

  • CAQH

  • The CAQH is a document hub that insurance companies use to maintain updated information on providers. You must update and reattest to your CAQH for the duration of your participation with insurance companies. 

    Please create a CAQH HERE. Only answer the required questions (!!)

    Please make sure the following are added to your CAQH. 


    Washington Area Clinical Center

    2905 Mitchellville Road Suite 204

    Bowie, MD 20716-3961

    301-701-6965

    info@waccenter.com

    NPI: 1609485010

    Tax ID: 814548356

    and

     

    New Millennial Counseling & Consulting

    7225 Hanover Parkway Suite C

    Greenbelt, MD 20770

    240-459-3074

    info@newmillennial.org 

    NPI:1245774116

    Tax ID: 814548356

     

    You must sign AND attest for your CAQH to be complete. You must also enter your settings and ensure your profile is accessible to any organization who requests it (only insurance carriers have access). 

  • Professional Liability Insurance

    Staff are required to maintain a minimum coverage of 1M/5M aggregate for the duration of their term with the organization. Please submit proof of coverage.
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  • License Changes and Updates

    Please submit a Screenshot or PDF copy of your Professional License IF YOUR LICENSE HAS CHANGED since you have joined the team. For example, if you were an LG and are now an LC, please upload your LC license. Also, if you were only licensed in one state, but are now licensed in two states, please upload the additional state license. If you are joining or a part of the Medical Team, please upload CURRENT copies of your CDS and DEA credentials.
  • Has you license level changes in the last 12 months? (E.g. LG to LC?)*
  • In the last 12 months, have you obtained licensure in another state?*
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  • Health Information

  • COVID- 19 Vaccine

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  • Baseline Individual TB Risk Assessment

    Please answer the questions below. Your answers to the questions will determine whether you are required to receive additional TB testing, per CDC guidelines. If you are required to receive additional testing, NMCC-WACC reimbuse your for the cost of testing.
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  • Website Photo and Bio

    Please answer the following questions thoughtfully as they will be used to construct your profile on the website.
  • Would you like to make updates to your profile on the website?*
  • Do you work with patients who are minors?*
  • In which states do you currently hold a professional license?*
  • NMCC and WACC current has a waiting list for in-person sessions. To incentive clinicians to accept clients on this list, a new in-person bonus shall apply to services provided to these clients. Are you able to provide any in-person services at the Bowie Office to clients on this list?*
  • Please select any special populations or treatment modalities you have experience treating*
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  • Attestation

  • Have you completed cultural competency training in the last 12 months?
  • Have you read the Most Recent Clinical Manual (Replaces the staff handout)
  • Should be Empty: