• 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.
  • Format: 000-000-0000.

  • Practice Information

  • Indicate the populations served. Check all that apply:*
  • Does practice have any Hospital Affiliations?*
  • Disorders and Treatment Modalities*
  • Rows

  • Service Locations

  • Number of Service Location/s*

  • Service Location 1

  • Located at:
  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Is Location Handicap Accessible?

  • Service Location 2

  • Located at:
  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Is Location Handicap Accessible?

  • Service Location 3

  • Located at:
  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Is Location Handicap Accessible?

  • Service Location 4

  • Located at:
  • Format: 000-000-0000.
  • Format: 000-000-0000.
  • Is Location Handicap Accessible?

  • Policies and Procedures

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  • Hours / Availability*
  • Appointment Availability*
  • Does Practice offer Telehealth Services?*

  • Providers

  • Number of Providers within Practice*

  • Provider 1

  • Date of Birth*
     / /
  • Indicate Primary Specialty*
  • Indicate all boards by which Provider holds a current certification*
  • Areas of Clinical Practice*
  • Does Provider prescribe medications?*

  • Provider 2

  • Date of Birth*
     / /
  • Indicate Primary Specialty*
  • Indicate all boards by which Provider holds a current certification*
  • Areas of Clinical Practice*
  • Does Provider prescribe medications?*

  • Provider 3

  • Date of Birth*
     / /
  • Indicate Primary Specialty*
  • Indicate all boards by which Provider holds a current certification*
  • Areas of Clinical Practice*
  • Does Provider prescribe medications?*

  • Additional Providers

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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

  • 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?
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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?
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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.

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