CommCare - Provider Preliminary Application Form

Any provider interested in becoming a part of CommCare's Provider Network is
asked to complete the following Preliminary Application. The information provided will enable CommCare to determine the need for additional providers according to geographic location and clinical service mix. This application may be completed online and submitted electronically or it may be downloaded and either mailed or faxed.

The complete CommCare Provider Preliminary Application Form is available for download in PDF or Word format.

Download Form [ PDF | Word ]

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PROVIDER PRELIMINARY APPLICATION (This is not an application for membership) This form is for informational purposes only Required Fields are denoted with an asterisk()
Submission Date:	9/4/2010 10:56:59 AM
*Name:
Phone:
Fax:
Profession:	Psychiatrist Licensed Psychologist LCSW(MO) LPC LSCSW(KS) ARNP Other:
Board Certified (Physicians only):	Yes No

*Name of Association:
*Primary Address:
Phone:

*Secondary Address:
Phone:

*Name of Additional Association:
*Primary Address:
Phone:

*Secondary Address:
Phone:

List all other Practicing Locations:

*Billing Address (if different):
*List the name(s) of other providers in your Association (include their specialty and any affiliation to the CommCare network):
Please describe your education and training:
*Degree(s) Held:
*Medical or Graduate School(s):
*Date(s) of Graduation:
*Residency/Clinical Internship/Practicum:
*Specialty:
*Begin Date/End Date:	to
*Program Director:
*Other Residencies/ Fellowships/ Special Certificates:
*Specialty:
*Begin Date/End Date:	to
*Program Director:
*List any unique services/procedures/ sub-specialties you provide within your specialty.
Do you have experience with the Medicaid population?	Yes No
If yes, please describe:
Do you have 24-hour coverage capability?	Yes No
*List all languages other than English that you speak.
*List your affiliation with other managed health care organizations (include name and type).

List the DSM-IV diagnoses and/or groups that you serve.
List any DSM-IV diagnoses and/or groups you would request not to receive as referrals.
Please identify (estimated) total number of patients seen weekly.

I request an application for membership within the CommCare provider network. I understand that this is not an application for membership. I also understand that I may not receive an application if I do not meet the criteria established or if there is no compelling network need for my specialty. In addition, falsification of this application in any of the above areas will immediately disqualify me from consideration for selection.
I agree