Step 1 of 5

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Personal Information

Full legal name(Required)

First Middle Last

Title(Required)

LPC

MSW

PhD

Other

Type of provider

PCP

Specialist

Hospitalist

Urgent Care

Have you ever gone by any other name?

Yes

LIST prior names below with dates

Date of Birth:(Required)

MM slash DD slash YYYY

Place of Birth (City, State/Province, Country)(Required)

SSN(Required)

Upload Driver's License or State Issued ID:

Max. file size: 512 MB.

Are you a citizen of the United States?

Yes

If no, country of citizenship:

Please Upload VISA:

Max. file size: 512 MB.

Have you ever served in the Military?

Yes

If yes, are you currently on active military duty?

Yes

List any languages you speak other than English:

Please Upload your CV / Resume

Max. file size: 512 MB.

Contact Information

Your Email Address(Required)

Enter Email Confirm Email

Personal Cell Phone(Required)

Home Address:

Street Address City State / Province / Region ZIP / Postal Code

Preferred method of communication for this application:(Required)

Text

Cell phone

Other

Credentials

NPI: Type 1

**NPI Username

NPI Password

(See notes)

Individual Medicare number:

Individual Medicaid number:

Do you have Medicaid outside of Oklahoma?(Required)

Yes

OHCA Username

OHCA Password

Board Certification Number:

(need certificate copy with dates and number)

Board Certification Date:

(need certificate copy with dates and number)

Upload Certificate:

Max. file size: 512 MB.

State License Number:

Licensing State:

Upload License 1:

Max. file size: 512 MB.

State License Number 2:

Licensing State 2 :

Upload License 2:

Max. file size: 512 MB.

CAQH Credentialing:

If you do not have this, we will set up a CAQH data file it. (See notes)

CAQH number:

**CAQH Username:

CAQH Password:

Practice Information

Name of Group

Practice Website

Primary Specialty:

Secondary Specialty:

Ages you treat:(Required)

Gender Limitations(Required)

None

Male Only

Female Only

Other

Days and hours of practice:

Practitioner Location Type

Office

Clinic

ASC

Hospital

Home

Other

Practitioner Primary Hospital Affiliation

Admitting Privileges

Yes

I don't know

Secondary Hospital Affiliation

Admitting Privileges

Yes

I don't know

Do you intend to practice at more than one location with this group?

Yes

List location individually:

Location City/Region

Street Address & ZIP

CLINICAL EXPERTISE (SPECIALTIES):

From the list below, select a maximum of six (6) specialty areas for which you have training and expertise. If you indicate more than six specialties, they will not be documented. These specialties will be used to assist Beacon Health Options in making clinically appropriate referrals. Please remember to select applicable specialties when applying for the specialty networks.

Addictions, Non-Chemical (S.ANC)

Adoption (S.ADP)

Affective Disorders (S.AFF)

Alcohol/ChemicalDependency(S.ACD)

Anger Management/Impulse Disorders (S.ANG)

Anxiety Disorders (S.ANX)

Applied Behavioral Analyst

Autism Spectrum Disorders (S.ASP)

Attention Deficit Hyperactivity Disorder (ADHD)

School-related problems (S.ADD)

Childhood Behavioral Disturbances(S.CBD)

Chronic Pain (S.CHP)

Co-Occurring Disorders (S.COD)

Death & Dying/Terminal Illness (S.CHT)

Disability Assessment (M.DSA)

Disability Treatment (S.DST)

Dissociative Identity Disorders (S.MPD)

Domestic Violence (S.VIO)

Gangs/Cults (S.GNG)

EatingDisorders(S.EAT)

Fitness for Duty Assessment M.FDE)

Forensics (S.FOR)

Gay/Lesbian/Bisexual/Transgender/Sexual (S.GLS)

Geropsychiatry/Alzheimers (S.GAL)

Grief/Bereavement (S.GRF)

Head Trauma (S.HTR)

Hearing Impaired (S.HIM)

HIV/AIDS (S.HIV)

Marital/Separation/Divorce (S.MAR)

Men's Issues (120C) S.MEN)

Mental Retardation/ Developmental Disabilities (S.MRI)

Military Lifestyle Issues (S.MIL)

Neuropsychology (S.NEU)

Obsessive Compulsive Disorder (S.OCD)

Panic/Phobias (S.PHO)

Personality Disorders (S.PER)

PhysicalAbusePerpetrators(S.PAP)

Physical Abuse Victims (S.PAV)

Post-Traumatic Stress Disorder (S.PSD)

Reactive Attachment Disorder (S.RAP)

Schizophrenia (S.SCH)

Severe & Persistent Mental lllness(S.SPM)

Sex Abuse Perpetrators (S.SAB)

Sex Abuse Victims (S.SAB)

Sexual Dysfunction (S.DYF)

Sleep Disorders (S.SLP)

Suboxone Therapy (S.SUB)

Trichotillomania (S.TRM)

Women's Issues (S.WMN)

Telehealth Services (S.THS)

THERAPEUTIC MODALITIES:

From the list below, please select a maximum of six (&) modality areas that you use when treating patients. These modalities will be used to assist Beacon Health Options in making clinically appropriate referrals. Please remember to select applicable modalities when applying for the specialty networks.

Behavior Modification Therapy (M.BEH)

Brief Therapy (M.BRF)

Child Therapy (M.CHI)

Child Therapy (Sy and younger) (M.CHY)

Cognitive Behavioral Therapy (M.COG)

Critical Incident Stress Management

Dialectical Behavioral Therapy (M.DBT)

DFWP (Drug Free Workplace; Federally Required training & consultations); EAP/ Organizational Development/ Workplace Issues; Stress Management (M.WRK)

ECT Inpatient (M.ECT)

ECT Outpatient (M.ECO)

Family Therapy (M.FAM)

Neuropsychological Testing (M.NSY)

Pastoral Counseling (M.CHR)

Play Therapy (M.PLY)

Psych Testing (M.PST)

Psychopharmacology (M.PSP)

Solution Focused Therapy (M.SFT)

Worker's Comp Evaluations (M.WCE)

Insurance

Do you have current liability insurance?(Required)

Yes

Upload copy of current liability insurance:

Max. file size: 512 MB.

Have you had previous carriers in the last 10 Years?(Required)

Yes

Upload copy of current liability insurance:If available, please upload copies:

Drop files here or

Max. file size: 512 MB.

{all_fields}

Terms and Conditions(Required)

I certify that everything contained herein is true and factual.

Phone

This field is for validation purposes and should be left unchanged.

Behavioral Health New Provider Application

Behavioral Health New Provider Application - Step 1

Personal Information

Contact Information

Credentials

Practice Information

Insurance

If you have questions about the on-boarding, please contact our office at 405-849-4016. We are happy to help!

Behavioral Health New Provider Application

Behavioral Health New Provider Application - Step 1

Personal Information

Contact Information

Credentials

Practice Information

Insurance

If you have questions about the on-boarding, please contact our office at 405-849-4016. We are happy to help!

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