Psyched Affiliate Application Form

The Psyched Group!

Psyched Provider Network Application Form
Name

First NameLast Name
Birth Date

MonthDayYear
Phone Number
Format: (000) 000-0000.
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?
Have you ever been denied malpractice insurance or brought before your state licensing board?
Are you currently in private practice?
Are you available to see clients at least ONE evening per week (5pm -8pm)?
What days per week would you like to see clients?
Will you be seeing clients virtually or in-person at one of our offices?
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?
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?

Other
List any insurances you are paneled but not listed above?
Do you have current malpractice insurance?
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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The Psyched Group!