Basic Information
First, Middle and Last name
*
Provider First Name
Provider Middle Name
Provider Last Name
Email Address
*
example@example.com
List all previous Last Names
*
Provider NPI
*
Provider DOB
*
-
Day
-
Month
Year
Provider Full SSN
*
Provider Current Home Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Do you practice in a state that requires Licensure?
*
Yes
No
Upload License Image
*
CLICK HERE TO UPLOAD THE IMAGE
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Choose a file
Cancel
of
Do you have liability insurance?
*
Yes
No
Upload Insurance Image
*
CLICK HERE TO UPLOAD THE IMAGE
Drag and drop files here
Choose a file
Cancel
of
Profile Data
Name of the ABA Group you will be joining?
*
Actual or Anticipated Hire Date
*
-
Day
-
Month
Year
Select all states you'll be servicing for the ABA group.
*
Please list all Insurance Companies you are enrolled for
*
Provider Type
*
Please Select
BT
RBT
BCaBA
BCBA
BCBA-D
SLP
OT
PT
Other
Provider Degree
*
Please Select
BA
BFS
BGS
BM
BS
BSEd
EdD
PhD
MAS
MA
MAT
MPA
MPH
MS
MSEd
MST
Other
Area of Expertise (in addition to ABA)
*
Please Select
ADD
ASD
CBT
DBT
PTSD
ADD/ADHD
Telemedicine
Play Therapy
Group Therapy
In-Home Therapy
Behavioral Therapy
Behavioral Analysis
Learning Disabilities
Psychological Testing
Behavior Modification
Co-Occurring Disorders
Developmental Disabilities
Behavioral Therapy for ASD
Anxiety and Panic Disorders
Psychotherapy - Psychologist
Anger Management/Impulse Disorders
Childhood/Adolescent Behavioral Disturbances
Developmental, Individual-differences and Relationship-based Model (DIR)
Other
List all Spoken Languages
*
Provider Treating Age Range
*
Your Typical Panel Size (Case Load)
*
Are you a Telehealth only Provider?
*
Yes
No
Are you an In-Home only Provider?
*
Yes
No
Have you completed a Cultural Competency Training Course? If yes, what date was it completed?
*
Gender
Please Select
Prefer Not to Disclose
Male
Female
Other
Provider Ethnicity
Please Select
Asian
White
Multiracial
Alaska Natives
Pacific Islander
African American
Hispanic or Latino
Prefer Not to Disclose
Other
CAQH PROFILE
CAQH ID
*
Email
*
example@example.com
CAQH Username
*
List all Spoken Languages
*
Provider Treating Age Range
*
Your Typical Panel Size (Case Load)
*
Are you a Telehealth only Provider?
*
Yes
No
Are you an In-Home only Provider?
*
Yes
No
Wrap Up Items
PLEASE REFORMAT ALL HEIC FILE TYPES INTO PDFS, JPGS, OR PNGS. TY!
Upload Resume
*
CLICK HERE TO UPLOAD THE FILE - PLEASE BE SURE TO ADD ALL STAR ABA TO YOUR RESUME
Drag and drop files here
Choose a file
Cancel
of
Upload Degree
*
CLICK HERE TO UPLOAD THE FILE
Drag and drop files here
Choose a file
Cancel
of
Upload Copy of Government Issued ( Driver's license, Passport, Etc.)
*
CLICK HERE TO UPLOAD THE FILE - THIS MUST BE CLEAR AND LEGIBLE
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Choose a file
Cancel
of
Optional Upload Copy of Social Security Card
*
CLICK HERE TO UPLOAD THE FILE - THIS MUST BE CLEAR AND LEGIBLE
Drag and drop files here
Choose a file
Cancel
of
Upload CPR/BLS Certification
*
CLICK HERE TO UPLOAD THE FILE
Drag and drop files here
Choose a file
Cancel
of
Additional Documents
*
PLEASE UPLOAD ANY ADDITIONAL DOCUMENTS AS INSTRUCTED BY YOUR GROUP ADMIN
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Choose a file
Cancel
of
Have you ever been convicted of a criminal offense (felony or misdemeanor)?
*
Yes
No
Has your license or certification ever been suspended?
*
Yes
No
Have you ever been named as a defendant in a profession liability action?
*
Yes
No
Are you covered under your own liability insurance policy?
*
Yes
No
Submit
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