Psyched Affiliate Application Form

The Psyched Group!

Psyched Provider Network Application Form
Name*

First NameLast Name
Birth Date

MonthDayYear
Phone Number*
Email*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Are you a United States citizens without a criminal conviction or pending case?

YesNo
Have you ever been denied malpractice insurance or brought before your state licensing board?

YesNo
Are you currently in private practice?

YesNo
Are you available to see clients at least ONE evening per week (5pm -8pm)?

YesNo
What days per week would you like to see clients?*

MondayFridayTuesdaySaturdayWednesdaySundayThursday
Will you be seeing clients virtually or in-person at one of our offices?

In-Person ONLYVirtual Telehealth ONLYa mix of both in-person and telehealth
References

Please list one(1) reference who is familiar with your work life.
Reference
Are you willing to work with children (ages 8-18) as well as adult?

I will work with ALL agesI will work with ADULTS ONLYI will work with CHILDREN ONLY
Credentialing Information

Please provide accurate information. If you are invited to join the group this information will be used to crednetial you with insurance panels and add you to group practice so you may accept health insurance plans.
SSN/TIN
License Type
License Number
State(s) of Licensure
NPI#
CAQH#
Medicaid#
Medicare#
Which health insurances are you currently panelled and able to accept as in-Network?

AetnaAnthem BlueBeacon Health / CarelonBlue Cross Blue ShieldCignaHarvard-PilgrimOptumUnited Healthcare / UBHTufts Health Plans (Commercial)Tufts Public Health Plans (Public)MedicareMedicaidMBHPNeighborhood Health PlanTricareOther
List any insurances you are paneled but not listed above?
Do you have current malpractice insurance?

YesNo
Personal & Professional Profiles

This section is optional, but helps us better understand who you are as you see yourself so we can make the best presentation to clients and patients on your behalf.
Sample Bio: Tell us how you would promote yourself to give us a sense of who you are (25-250 words)?
Resume: Please upload your resume here to give us a greater picture of your career.

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Professional Photo: Please upload a professional photo to help us better know who you are.

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Should be Empty:

The Psyched Group!