Clinician Registration Form

We are asking clinicians billing our department for services to please provide some information so we can approve you as a vendor in this benefit program. Please fill in the form below

This process is provided for clinicians who have established a client relationship with a Menlo Park Fire District employee. Please select Yes in drop down if you meet this requirement and continue to answer the questions below.*

Clinician Full Name*

First NameLast Name

Clinician Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Clinician Phone Number*

Area CodePhone Number

Clinician E-mail*

Business Name (as shown on your W-9)*

Do you have previous experience working with first responders? *

How long have you been practicing?*

What modality or style of therapy do you practice?*

What is your session rate for services?*

Please list any specialty training / experience (PTSD, EMDR, family therapy, etc.). *

Additional Information (Limit 200 characters)

0/200

Are you accepting new patients?*

YesNo

Mental Health Wellness Program Doc

I have downloaded and read the Mental Health and Wellness Program Policy from the link above and will comply with all aspects of the program.*

YesNo

- Mental Health Wellness Program Appendix A

- Sample Bill Appendix B

I have reviewed the billing instructions from the link above and the sample bill. I understand the billing process and will comply with the procedures.*

YesNo

Conflict of Interest Policy: No director, officer, employee, or agent of the District may participate in any procedure, tasks, or decisions relative to initiation, evaluation, award, or administration of a contract if a conflict of interest, real or apparent, exists. Such a conflict of interest arises when (a) the director, officer, employee, or agent, (b) any member of his or her immediate family, (c) his or her business associate, or (d) an organization which employs, or which is about to employ, any of the above described individuals has a financial or other interest in a firm that participates in a District procurement process or that is selected for an award. The standards governing the determination as to whether such an interest exists are set forth in the Political Reform Act (Section81000 et seq. of the California Government Code) and in Sections 1090 et seq.of the California Government Code.I have read the Conflict of Interest policy and certify that there is no conflict of interest between myself and/or my practice and the District.*

YesNo

Please upload your License, W-9 and any other supporting documents you deem necessary

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Please verify that you are human*