Certified Provider Application | Practice
The application below is intended for provider-based services and is only a request for information, not an offer to contract. Your Application Contact will receive a written response from Scandia Wellness Systems upon receipt of this application within 10 business days.
rrhone@scandiasystems.com
example@example.com
Application Contact
*
Phone Number
*
Provider Affiliation
*
Please Select
Self
Employee
Consultant
E-mail
*
Practice Information
Practice / Office Name
*
Provider name if not applicable
Mailing Address
*
Street Address Line 2
State
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Indicate the populations served. Check all that apply:
*
Child (0-12 years)
Adolescent (13-17 years)
Adult (18-59 years)
Geriatric (60+ years)
Website URL
Does practice have any Hospital Affiliations?
*
Yes
No
Hospital Affiliations
Disorders and Treatment Modalities
*
Alcohol and substance use
Autism – Applied Behavioral Analysis (ABA)
Autism – testing and assessment
Autism – treatment
Developmental disorders
Dialectical Behavioral Therapy (DBT)
Cognitive Behavioral Therapy (DBT)
Dual diagnosis
Eating disorder
Exposure and Response Prevention (ERP) Therapy
Eye Movement Desensitization & Reprocessing (EMDR)
MAT: Medically Assisted Treatment
Neuropsychological testing
Pain management
Sexual disorders
Other
MAT medications:
*
Are the following used by providers, and how?
Methadone
Not Utilized
Utilized: By prescription
Utilized: With onsite dispensing
Utilized: By prescription AND onsite dispensing
Buprenorphine
Not Utilized
Utilized: By prescription
Utilized: With onsite dispensing
Utilized: By prescription AND onsite dispensing
Vivitrol
Not Utilized
Utilized: By prescription
Utilized: With onsite dispensing
Utilized: By prescription AND onsite dispensing
Suboxone
Not Utilized
Utilized: By prescription
Utilized: With onsite dispensing
Utilized: By prescription AND onsite dispensing
Other (Explain below)
Not Utilized
Utilized: By prescription
Utilized: With onsite dispensing
Utilized: By prescription AND onsite dispensing
Other MAT medication/s used
Service Locations
Number of Service Location/s
*
1
2
3
4
4+
Service Location 1
Located at:
Mailing Address
Other Address
Service Location Phone #
Address
Street Address
Suite
City
State / Province
Postal / Zip Code
Office Fax
Is Location Handicap Accessible?
Yes
No
Office Email
Service Location 2
Office Name
If different
Located at:
Mailing Address
Other Address
Service Location Phone #
Address
Street Address
Suite
City
State / Province
Postal / Zip Code
Office Fax
Is Location Handicap Accessible?
Yes
No
Office Email
Service Location 3
Office Name
If different
Located at:
Mailing Address
Other Address
Service Location Phone #
Address
Street Address
Suite
City
State / Province
Postal / Zip Code
Office Fax
Is Location Handicap Accessible?
Yes
No
Office Email
Service Location 4
Office Name
If different
Located at:
Mailing Address
Other Address
Service Location Phone #
Address
Street Address
Suite
City
State / Province
Postal / Zip Code
Office Fax
Is Location Handicap Accessible?
Yes
No
Office Email
Type a question
Policies and Procedures
Please submit copies of existing written policies and procedures that reference services offered or recommended, and that demonstrate a commitment to best practices, effective recovery, and continuous improvement.
*
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Hours / Availability
*
Business Hours Only
Evening appointments (after 5p)
Weekend appointments
Appointment Availability
*
Standard
Crisis stabilization 24/7
Crisis stabilization non-24/7
Intermediate care (urgent)
Meet and greet (non-physicians only)
Does Practice offer Telehealth Services?
*
Yes
No
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Providers
Number of Providers within Practice
*
1
2
3
3+
Provider 1
First Name
*
Last Name
*
Gender
*
Please Select
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Tax ID
NPI
Medicare Identification Number
License Number
*
Primary Degree Type
*
Please Select
None
BA-Bachelor Of Arts
BAN-Bachelor Of Arts in Nursing
BS-Bachelor Of Science
BSN-Bachelors Of Science And Nursing
BSW-Bachelor Of Social Work
CAS-Certificate Of Advanced Study
CD-Counselor Without Degree
DED-Doctor Of Education
DMFT-Doctorate Of Marriage & Family Therapy
DMIN-Doctor Of Ministry
DNP-Doctor Of Nursing Practice
DNSC-Doctorate Of Nursing Science
DO-Doctor Of Osteopath
DPH-Doctorate Of Public Health
DSW-Doctorate Of Social Work
ED-Bachelor Of Education
EDD-Doctorate Of Education
EDM-Masters Of Education
EDS-Educational Specialist
MACP-Master Of Clinical Psych
MA-Master Of Arts
MAT-Master Of Arts Therapist
MBBS-Bachelor Of Medicine / Bachelor Of Surgery
MBS-Masters Of Behavioral Science
MCAP-Master Certified Addictions Professional
MC-Master Of Counseling
MDIV-Master Of Divinity
MD-Medical Doctor
MED-Master Of Education
MEQ-Master Equivalency
MHDL-Masters IN Human Development And Learning
MHR-Masters Of Human Relations
MHS-Master Of Human Services
MMFT-Master Of Marriage & Family Therapy
MMH-Masters Of Mental Health
MN-Master Of Nursing
MPA-Master Of Public Administration
MPH-Master Of Public Health
MPS-Master Of Professional Studies
MPSY-Masters IN Psychology
MRC-Master Of Rehab Counseling
MRE-Masters IN Religion And Education
MSCC-Master Of Science Clinical Counseling
MSED-Master Of Science/Education
MS-Master Of Science
MSN-Master Of Science Nursing
MSSA-Master Of Social Science Administration
MSS-Master Of Social Science
MSSW-Master Of Science Social Worker
MSW-Master Social Worker
MTH-Master Of Theology
MTS-Master Of Theologic Studies
PA-Physician Assistant Program
PHD-Doctor Of Philosophy
PHD-R-Doctor Of Philosophy IN Rehabilitation
PSYD-Doctor Of Psychology
SCD-Doctorate Of Science
THD-Doctorate Of Theology
Other
Professional Licenses / Certifications
*
None
APN-Advanced Practice Nurse
APNP-Advanced Practice Nurse Prescriber
APPN-Advanced Practice Professional Nurse
APRN-Advanced Practice Registered Nurse
APRNPMH-Advanced Practice Registered Nurse Psychiatric Mental Health
ARNP-Advanced Registered Nurse Practitioner
CNP-Clinical Nurse Practitioner
CNS-Clinical Nurse Specialist
CNS-PMH-Clinical Nurse Specialist, Psychiatric/Mental Health
CP-Clinical Psychologist
CPS-Certified Prevention Specialist
CRNP-Certified Registered Nurse Practitioner
CRNPPMH-Certified Registered Nurse Practitioner Psychiatric Mental Health
DO-Doctor Of Osteopath
LCP-Licensed Clinical Psychologist
LEP-Licensed Educational Psychologist
LPA-Licensed Psychological Associate
LP-Licensed Psychologist
MD-Doctor Of Medicine
MPAP-Medical Psychologist- Advanced Practice
MP-Medical Psychologist
NP-Nurse Practitioner
PAC-Physician Assistant-Certified
PMHCNS-Psychiatric Clinical Nurse Specialist
PMHNP-Psychiatric And Mental Health Nurse Practitioner
RNCS-Registered Nurse Clinical Specialist
RNP-Registered Nurse Practitioner
Indicate Primary Specialty
*
Psychiatrist
Psychiatric nurse
Addictionologist
Physician Assistant
Other
Indicate all boards by which Provider holds a current certification
*
None
American Board of Psychiatry/Neurology
American Osteopathic Association
American Society of Addiction Medicine
American Board of Preventive Medicine
American Board of Clinical Health Psychology
American Board of Medical Specialists
Other
Areas of Clinical Practice
*
Adoption issues
AIDS/HIV
Anger management
Anxiety disorder
Bipolar disorder
Bisexual/Gay/Lesbian
Borderline personality disorder
Conduct/disruptive disorder
Cultural/Ethnic Issues
Depression
Dissociative disorder
Domestic violence
Emergency Responder
Faith-based counseling
Family therapy
Fertility issues
Gambling addictions
Gender Identity/Transgender
Grief/loss
Healthcare Professional
Home visits
Marital/couples therapy
Medical issues/illness
Minority issues
Obsessive Compulsive D/O
Panic disorder
Phobias
Psychological testing
Psychotic disorders
PTSD
Sexual abuse/incest
Transcranial Magnetic Stimulation (TMS)
Other
Does Provider prescribe medications?
*
Yes
No
DEA Number
Provider 2
First Name
*
Last Name
*
Gender
*
Please Select
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Tax ID
NPI
Medicare Identification Number
License Number
*
Primary Degree Type
*
Please Select
None
BA-Bachelor Of Arts
BAN-Bachelor Of Arts in Nursing
BS-Bachelor Of Science
BSN-Bachelors Of Science And Nursing
BSW-Bachelor Of Social Work
CAS-Certificate Of Advanced Study
CD-Counselor Without Degree
DED-Doctor Of Education
DMFT-Doctorate Of Marriage & Family Therapy
DMIN-Doctor Of Ministry
DNP-Doctor Of Nursing Practice
DNSC-Doctorate Of Nursing Science
DO-Doctor Of Osteopath
DPH-Doctorate Of Public Health
DSW-Doctorate Of Social Work
ED-Bachelor Of Education
EDD-Doctorate Of Education
EDM-Masters Of Education
EDS-Educational Specialist
MACP-Master Of Clinical Psych
MA-Master Of Arts
MAT-Master Of Arts Therapist
MBBS-Bachelor Of Medicine / Bachelor Of Surgery
MBS-Masters Of Behavioral Science
MCAP-Master Certified Addictions Professional
MC-Master Of Counseling
MDIV-Master Of Divinity
MD-Medical Doctor
MED-Master Of Education
MEQ-Master Equivalency
MHDL-Masters IN Human Development And Learning
MHR-Masters Of Human Relations
MHS-Master Of Human Services
MMFT-Master Of Marriage & Family Therapy
MMH-Masters Of Mental Health
MN-Master Of Nursing
MPA-Master Of Public Administration
MPH-Master Of Public Health
MPS-Master Of Professional Studies
MPSY-Masters IN Psychology
MRC-Master Of Rehab Counseling
MRE-Masters IN Religion And Education
MSCC-Master Of Science Clinical Counseling
MSED-Master Of Science/Education
MS-Master Of Science
MSN-Master Of Science Nursing
MSSA-Master Of Social Science Administration
MSS-Master Of Social Science
MSSW-Master Of Science Social Worker
MSW-Master Social Worker
MTH-Master Of Theology
MTS-Master Of Theologic Studies
PA-Physician Assistant Program
PHD-Doctor Of Philosophy
PHD-R-Doctor Of Philosophy IN Rehabilitation
PSYD-Doctor Of Psychology
SCD-Doctorate Of Science
THD-Doctorate Of Theology
Other
Professional Licenses / Certifications
*
None
APN-Advanced Practice Nurse
APNP-Advanced Practice Nurse Prescriber
APPN-Advanced Practice Professional Nurse
APRN-Advanced Practice Registered Nurse
APRNPMH-Advanced Practice Registered Nurse Psychiatric Mental Health
ARNP-Advanced Registered Nurse Practitioner
CNP-Clinical Nurse Practitioner
CNS-Clinical Nurse Specialist
CNS-PMH-Clinical Nurse Specialist, Psychiatric/Mental Health
CP-Clinical Psychologist
CPS-Certified Prevention Specialist
CRNP-Certified Registered Nurse Practitioner
CRNPPMH-Certified Registered Nurse Practitioner Psychiatric Mental Health
DO-Doctor Of Osteopath
LCP-Licensed Clinical Psychologist
LEP-Licensed Educational Psychologist
LPA-Licensed Psychological Associate
LP-Licensed Psychologist
MD-Doctor Of Medicine
MPAP-Medical Psychologist- Advanced Practice
MP-Medical Psychologist
NP-Nurse Practitioner
PAC-Physician Assistant-Certified
PMHCNS-Psychiatric Clinical Nurse Specialist
PMHNP-Psychiatric And Mental Health Nurse Practitioner
RNCS-Registered Nurse Clinical Specialist
RNP-Registered Nurse Practitioner
Indicate Primary Specialty
*
Psychiatrist
Psychiatric nurse
Addictionologist
Physician Assistant
Other
Indicate all boards by which Provider holds a current certification
*
None
American Board of Psychiatry/Neurology
American Osteopathic Association
American Society of Addiction Medicine
American Board of Preventive Medicine
American Board of Clinical Health Psychology
American Board of Medical Specialists
Other
Areas of Clinical Practice
*
Adoption issues
AIDS/HIV
Anger management
Anxiety disorder
Bipolar disorder
Bisexual/Gay/Lesbian
Borderline personality disorder
Conduct/disruptive disorder
Cultural/Ethnic Issues
Depression
Dissociative disorder
Domestic violence
Emergency Responder
Faith-based counseling
Family therapy
Fertility issues
Gambling addictions
Gender Identity/Transgender
Grief/loss
Healthcare Professional
Home visits
Marital/couples therapy
Medical issues/illness
Minority issues
Obsessive Compulsive D/O
Panic disorder
Phobias
Psychological testing
Psychotic disorders
PTSD
Sexual abuse/incest
Transcranial Magnetic Stimulation (TMS)
Other
Does Provider prescribe medications?
*
Yes
No
DEA Number
Provider 3
First Name
*
Last Name
*
Gender
*
Please Select
Male
Female
Date of Birth
*
/
Month
/
Day
Year
Tax ID
NPI
Medicare Identification Number
License Number
*
Primary Degree Type
*
Please Select
None
BA-Bachelor Of Arts
BAN-Bachelor Of Arts in Nursing
BS-Bachelor Of Science
BSN-Bachelors Of Science And Nursing
BSW-Bachelor Of Social Work
CAS-Certificate Of Advanced Study
CD-Counselor Without Degree
DED-Doctor Of Education
DMFT-Doctorate Of Marriage & Family Therapy
DMIN-Doctor Of Ministry
DNP-Doctor Of Nursing Practice
DNSC-Doctorate Of Nursing Science
DO-Doctor Of Osteopath
DPH-Doctorate Of Public Health
DSW-Doctorate Of Social Work
ED-Bachelor Of Education
EDD-Doctorate Of Education
EDM-Masters Of Education
EDS-Educational Specialist
MACP-Master Of Clinical Psych
MA-Master Of Arts
MAT-Master Of Arts Therapist
MBBS-Bachelor Of Medicine / Bachelor Of Surgery
MBS-Masters Of Behavioral Science
MCAP-Master Certified Addictions Professional
MC-Master Of Counseling
MDIV-Master Of Divinity
MD-Medical Doctor
MED-Master Of Education
MEQ-Master Equivalency
MHDL-Masters IN Human Development And Learning
MHR-Masters Of Human Relations
MHS-Master Of Human Services
MMFT-Master Of Marriage & Family Therapy
MMH-Masters Of Mental Health
MN-Master Of Nursing
MPA-Master Of Public Administration
MPH-Master Of Public Health
MPS-Master Of Professional Studies
MPSY-Masters IN Psychology
MRC-Master Of Rehab Counseling
MRE-Masters IN Religion And Education
MSCC-Master Of Science Clinical Counseling
MSED-Master Of Science/Education
MS-Master Of Science
MSN-Master Of Science Nursing
MSSA-Master Of Social Science Administration
MSS-Master Of Social Science
MSSW-Master Of Science Social Worker
MSW-Master Social Worker
MTH-Master Of Theology
MTS-Master Of Theologic Studies
PA-Physician Assistant Program
PHD-Doctor Of Philosophy
PHD-R-Doctor Of Philosophy IN Rehabilitation
PSYD-Doctor Of Psychology
SCD-Doctorate Of Science
THD-Doctorate Of Theology
Other
Professional Licenses / Certifications
*
None
APN-Advanced Practice Nurse
APNP-Advanced Practice Nurse Prescriber
APPN-Advanced Practice Professional Nurse
APRN-Advanced Practice Registered Nurse
APRNPMH-Advanced Practice Registered Nurse Psychiatric Mental Health
ARNP-Advanced Registered Nurse Practitioner
CNP-Clinical Nurse Practitioner
CNS-Clinical Nurse Specialist
CNS-PMH-Clinical Nurse Specialist, Psychiatric/Mental Health
CP-Clinical Psychologist
CPS-Certified Prevention Specialist
CRNP-Certified Registered Nurse Practitioner
CRNPPMH-Certified Registered Nurse Practitioner Psychiatric Mental Health
DO-Doctor Of Osteopath
LCP-Licensed Clinical Psychologist
LEP-Licensed Educational Psychologist
LPA-Licensed Psychological Associate
LP-Licensed Psychologist
MD-Doctor Of Medicine
MPAP-Medical Psychologist- Advanced Practice
MP-Medical Psychologist
NP-Nurse Practitioner
PAC-Physician Assistant-Certified
PMHCNS-Psychiatric Clinical Nurse Specialist
PMHNP-Psychiatric And Mental Health Nurse Practitioner
RNCS-Registered Nurse Clinical Specialist
RNP-Registered Nurse Practitioner
Indicate Primary Specialty
*
Psychiatrist
Psychiatric nurse
Addictionologist
Physician Assistant
Other
Indicate all boards by which Provider holds a current certification
*
None
American Board of Psychiatry/Neurology
American Osteopathic Association
American Society of Addiction Medicine
American Board of Preventive Medicine
American Board of Clinical Health Psychology
American Board of Medical Specialists
Other
Areas of Clinical Practice
*
Adoption issues
AIDS/HIV
Anger management
Anxiety disorder
Bipolar disorder
Bisexual/Gay/Lesbian
Borderline personality disorder
Conduct/disruptive disorder
Cultural/Ethnic Issues
Depression
Dissociative disorder
Domestic violence
Emergency Responder
Faith-based counseling
Family therapy
Fertility issues
Gambling addictions
Gender Identity/Transgender
Grief/loss
Healthcare Professional
Home visits
Marital/couples therapy
Medical issues/illness
Minority issues
Obsessive Compulsive D/O
Panic disorder
Phobias
Psychological testing
Psychotic disorders
PTSD
Sexual abuse/incest
Transcranial Magnetic Stimulation (TMS)
Other
Does Provider prescribe medications?
*
Yes
No
DEA Number
Additional Providers
Please upload resumes of all providers listed above.
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Does any provider hold ownership, executive, or membership-level positions in other companies/organizations that offer (a) drug and alcohol addiction treatment services, (b) laboratory services, (c) billing services, or (d) online/call center drug treatment information/referral services
Yes
No
Please list them here with the name, company type and principal connected.
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Terms and Disclosures
Has provider, or any medical practitioner associated with provider, been the subject of disciplinary action by your state regulatory authorities within the last 5 years?
Yes
No
Please upload a summary of events related to the discipline and any corrective actions.
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Has provider been the subject of, or a party to, any litigation commenced, resolved, or otherwise addressed relating to the provision of services at any time in the last 10 years?
Yes
No
Please upload a summary that describes the events related to the fine, penalty, judgment, or settlement, and any corrective actions that have been put in place.
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Scandia Wellness Systems (SWS) was founded to improve community well-being through better healthcare, promote collaboration among providers, control costs, and stay innovative in healthcare advancements.
Upon approval, a Participating Provider Agreement will be extended to the Facility.
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