TNRS- Clinical and PRS Enrollment

Clinical Resource and PRS Enrollment

Please use the following to submit your certifications, credentials, and or transcripts/diploma needed to verify the level of services you can provide on behalf of our organizations.
Personnel Full Name*

First NameLast Name
Entity name (if applicable)
Are you using a LLC or other company to provide services? If so, please list that name here.
Professional Email Address*
example@example.com
Phone Number*
Please enter a valid phone number.
Professional Phone Number (if different from personal)
Please enter a valid phone number.
Legal mailing address *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Assigned agency or entity you are working with *
Current certification status*
Peer Service Providers

This section only applies to Peer Recovery Specialists
Please upload a copy of your PRS Certification *

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Please upload your diploma or transcripts if you have a degree that applies to this field

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Clinical Service Providers

This section only applies to clinicians
Individual NPI #
CAQH ID #
***Your CAQH profile needs to be updated and attested for outside parties to pull the information***
Please upload a copy of your insurance policy - Mostly commonly HPSO

Please be sure to name B&B Group, DBA True North Recovery Services as additionally insured on your policy
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Please upload two forms of Identification*

Driver's license, passport, birth certificate, social security, and or military ID
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System Access Control
PRS/Coach (Standard permissions)Supervisor / Manager - No financial visbilitySupervisor / Manager - With financial visibility (Counselor activity)Clinical Access - Ability to complete and release treatmentsClinical Management - Ability to approve treatments and notesClinical Access + Financial Reporting
Any special permission needs or requests for this user?
Is this users permissions the same as another? if so, please provide that existing user name.
Reliatrax User Name
You hereby certify the information provided is true and correct to the best of your knowledge. Upon receipt, a member of our staff will follow up with you to confirm your registration and provide access to our EMR system, or request additional information as needed to complete your enrollment.

Thank you,

TNRS Compliance Team
Signature*

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Clinical Resource and PRS Enrollment

Peer Service Providers

Clinical Service Providers

System Access Control