PVP - ACMS Mental Health Provider Contract Application/Annual Renewal

ACMS PVP Mental Health Provider Contract Renewal/Application

This is a multi-phase form. For initial inquiries, you will only need to fill out limited information for ACMS to decide if you meet the minimum qualifications for contracted mental health providers (MHPs). If we select you for an interview and you meet our internal requirements, we will have you come back and finish the more lengthy version of this form. Once you put your name and email address into those fields, you may save progress on this form at any time, with a button at the bottom of the form.
This is my first time applying as an ACMS Contract MHP*

Yes - Initial Inquiry only/repeat applicationYes - Completing Required PaperworkNo - I have changes to make and/or upload annual forms
Minimal Licensure*

Idaho Licensed Clinical Social Worker (LCSW)Idaho Licensed Clinical Professional Counselor (LCPC)Idaho Licensed Marriage Family Therapist (LMFT)Idaho Licensed Psychologist (Psy-D/PhD)Psychiatrist (Psychotherapy Only)Other
At this time, our program only allows for Idaho Licensed LCSWs, LCPCs, LMFTs, Psychologists, and Psychiatrists. However, if you are interested in being considered in the future, sure our policies change as we develop, please submit your contact information.
MHP Name*

First Name Last Name
Your Email (not public)*
example@example.com
Personal Contact Number (not public)*

Area Code Phone Number

MHP Public Listing Information
The nature of our program is that many physicians or other clinicians need urgent and timely access to mental health because of their peculiar work hours and blocks. To this end, accessibility and availability of appointments under certain circumstances might want to be made within 24-48 hours.
Does your appointment calendar currently allow for urgent or timely requests for appointments made by our members within that time frame?

YesPerhaps-I would need to know moreNo
At this time, we are looking for MHPs who have availability that meets the need of our particular member population. When your calendar opens up for more urgently made appointments, please check back with us.
Days and Hours of General Availability
Please describe your experience working with medical professionals and understanding of the occupational challenges they face and what drives them.*
Appointment Phone Number (public)

Area Code Phone Number
Appointment Email (public)
example@example.com
Preferred method of appointment making
(e.g. email or phone call, leave message, allow up to 24 business hours, etc)
Preferred Appointment Method

In-PersonTelehealthEither
Practice Name (if different than first and last or if incorporated or LLC)
Address of Clinic

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

MHP Practice and Billing Details
Checks should be made out to

MHP's NamePractice Name
Billing Contact Name (if not MHP), Phone, Email

Education and Qualifications
Masters Degree/University/Year Graduated
Doctoral Degree/University/Year Graduated
Applicable Idaho Department of Occupational Licensure #1

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Upload a copy of your your current licensure Cancelof
Occupational License#1 Expiration Date

MonthDay Year
Date
Applicable Idaho Department of Occupational Licensure #2

Browse Files
Upload a copy of your your current licensure Cancelof
Occupational License #2 Expiration Date

MonthDay Year
Date
Applicable Idaho Department of Occupational Licensure #3

Browse Files
Upload a copy of your your current licensure Cancelof
Occupational License #3 Expiration Date

MonthDay Year
Date
List any other CURRENT certifications you hold (EMDR, EFT, etc.)
Specific treatment foci or modalities to be listed on web page
see https://www.physicianvitality.org/pvp-therapists for existing listing samples
Do you have any potential conflict of interest in terms of serving ACMS member physicians, nurse practitioners, physician assistants, etc. Examples might include: Serving on a board/committee that regulates or investigates potential ACMS member clients or as part of your practice, having a close family relative who is a licensed medical professional and potentially/actually an ACMS member, etc. This is not a disqualification, but should be disclosed for explanation.
Please provide a physician of reference for us that you know professionally or personally (who is not a client). Describe your relationship to them and their contact information (phone/email) where we could reach them.
Please review your listing at this site and note any changes you need made: https://www.adamedicalsociety.org/pvp-therapists

MHP Forms
For all MHPs participating in the Physician Vitality Program, this paperwork must be completed before billing will be processed for any sessions.
Organizational/Personal W-9 (if not already submitted)

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Find the latest form at www.irs.gov/pub/irs-pdf/fw9.pdf Cancelof
Copy of Current Professional Liability Policy Limits Page with Ada County Medical Society listed as additional insured

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Cancelof
Liability Policy Expiration Date

MonthDay Year
Date
Signed Copy of Annual Program Contract

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Cancelof

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ACMS PVP Mental Health Provider Contract Renewal/Application