Espyr Network Provider Application – Espyr Providers Site

Please type or print legibly.

If you have questions please call or email our Provider Relations Department at 800-522-1073 or providerrelations@espyr.com between 8:30am-5:00pm Eastern time, Mon.-Fri.

Name*

First Middle Last

License Type (e.g. LPC, LMFT.etc.)*

The information below is OPTIONAL and is only for the purpose of accommodating a stated client preference.

Race
American Indian
African-American
Asian-American
Caucasian
Indian
Hispanic

Sex
Male
Female

Religion
Christian
Jewish
Muslim

Date of Birth*
MM slash DD slash YYYY

E-mail Address*

Website Address

Office Phone Number*

Mobile Phone Number*

Preference for receiving information / forms:*
Mail
E-mail

Independent Practice License

List below all states in which you are licensed for independent practice:

Primary state of licensure*

Date first issued*
MM slash DD slash YYYY

License Type (e.g. LPC, LMFT.etc.)*

License Number*

Expiration Date*
MM slash DD slash YYYY

Secondary state of licensure

Date first issued
MM slash DD slash YYYY

License Type (e.g. LPC, LMFT.etc.)

License Number

Other licensure or certification

Expiration Date
MM slash DD slash YYYY

Malpractice Insurance

Name of Malpractice Insurance Carrier:*

Address*
Street Address Suite # City State ZIP Code

Effective Date:*
MM slash DD slash YYYY

Expiration Date:*
MM slash DD slash YYYY

Terms of Insurance per incident:*

Aggregate Amount:*

Types of EAP Clients You Serve*
To help us make appropriate referrals, please tell us more about your practice and preferences. Check all the types of these presenting problems, conditions or clients that you feel professionally competent to serve for EAP assessment, referral or short-term counseling. Please note: Best EAP practices encourage clinicians to screen all EAP clients for possible work-related and substance abuse problems.
Adjustment Disorders
Adolescents ( aged 12 and older)
Adoption
Adult Sexual Abuse
Affective Disorders ( Depression, Bipolar D/O, etc.)
AIDS and HIV
Alcohol and Drug Abuse Screening and Referral
Anxiety Disorders
Attention Deficit Hyperactivity Disorder
Child Abuse - Sexual, Physical, Emotional
Children (ages 6-11)
Preschool (ages 5 and below)
Chronic/Terminal Illness
Co-dependency
Dissociative Disorders
Domestic Violence
Military Personnel/Veterans
DOT Qualified SAP
EAP, work-related, or occupational problems
Eating Disorders
Faith Based Counseling
Geriatric Issues
Law Enforcement/Fire/Military/Emergency personnel
Infertility
Loss, Bereavement and Grief
Marriage/Couples Issues
Family Issues
Personality Disorders
Post-Traumatic Stress Disorder
Sexual Dysfunction
Thought Disorders
Telephonic Counseling
Veterans and Veterans' Readjustment
Other

Please add any other presenting problems or conditions you are professionally competent to serve that are not listed in the prior question.

Special Populations You Serve:*
Select All
African-American
Asian-American
Hispanic
Native American
Hearing Impaired
Gay and Lesbian
Jewish
Christian
Other

Treatment Modalities Practiced:*
Select All
Individual
Family
Group
Couples

Do you conduct counseling in any language other than English?*
Spanish
French
German
American Sign Language
Other
None

We seek clinicians with prior experience serving EAP clients. How many years experience do you have as an EAP service provider?*
(in years)

If you have prior experience with other EAP companies, please list the names of those EAP companies:*

Please list experience addressing work-related issues (work/life balance, work-related stress, etc.)*

Do you conduct Critical Incident Stress Debriefings?*
YES
NO

If Yes, please list your CISD training, and any comments about your experience (Please attach your CEU Certificate for training.)*

Approximately how many CISDs have you conducted in the last 5 years?*

If you offer training services, please check the presentations that you can conduct*
Select All
EAP Employee Orientation
Drug Free Workplace
EAP Supervisory Training
Other Workshops or Lunch and Learn presentations*

* Please list topics that you have presented:

Please provide answers for the following questions

1. What is your experience facilitating trainings?*

2. Have you provided EAP trainings before?*

3. Have you ever provided webinars for organizations?*

4. Have you facilitated warnings that received survey results? If so, what were the results?*

5. Do you have preferred topics that you like to present? What are your specializations?*

6. What topics would not be within your expertise? (Feel free to see the attached catalog to get an idea of the topics Espyr provides)*

7. Have you provided trainings, Critical Incident Responses or any other onsite services for government or commercial organizations? If so, please provide some examples of the services and the organizations.*

8.If required by the organization requesting the training, are you comfortable with providing a background check?*

9. What do you enjoy about presenting?*

10. Do you have a reference that could speak to your presentation ability?*

Primary Office Information

Mailing Address:*
YES
NO

Practice Name:
(if applicable)

Primary Office Address*
Street Address Suite # City State ZIP Code

Office Phone Number*

Fax Number*

Office Manager*
If applicable, or the contact person for your practice if not yourself:

Handicapped accessible?*
YES
NO

Office located separate from residence?*
YES
NO
Espyr prohibits in-home offices

May we leave confidential client referral information on your office voicemail or answering system?*
YES
NO

Does your office voicemail or answering system greeting inform callers what to do if they are in a crisis or having an emergency and cannot reach you?*
YES
NO
All providers are required to have Crisis/Emergency Greetings

Hours of Operation*
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Please indicate your actual practice hours each day at this location, e.g. 9:00am to 5:00pm.

Make checks payable to (name must match the tax ID owner name on file with IRS for the TIN listed below)

Name*
First Last

Tax Identification Number (TIN)*

Check appropriate box :*
Individual / Sole proprietor
Corporation
Partnership

Are you 1099 eligible?*
YES
NO

Secondary Office Information

Mailing Address:
YES
NO

Practice Name:
(if applicable)

Secondary Office Address
Street Address Suite # City State ZIP Code

Office Phone Number

Fax Number

Office Manager
If applicable, or the contact person for your practice if not yourself:

Handicapped accessible?
YES
NO

Office located separate from residence?
YES
NO
Espyr prohibits in-home offices

Hours of Operation
Monday Tuesday Wednesday Thursday Friday Saturday Sunday

Please indicate your actual practice hours each day at this location, e.g. 9:00am to 5:00pm.

Make checks payable to (name must match the tax ID owner name on file with IRS for the TIN listed below)

Name
First Last

Tax Identification Number (TIN)

Check appropriate box :
Individual / Sole proprietor
Corporation
Partnership

Are you 1099 eligible?
YES
NO

Mailing Address (if it is different from your Primary or Secondary Office location)
Street Address Suite # City State ZIP Code

Please list any additional office locations below.
Street Address Suite # City State ZIP Code

What are your provisions for after-hours response to emergency client calls? Please include telephone number if different than above:*

Do you have 7 day/week, 24-hour/day back up and/or on-call coverage:
YES
NO

Who do you use for coverage?

Please list any other employment in addition to your private practice:

Please list insurance or managed care plans that your practice accepts:

Please list the name of at least one substance abuse treatment program or facility, and one mental health program or facility to which you commonly refer clients in need of higher levels of care, or a specialized program such as a substance abuse IOP:

Name

Location

Name

Location

Please List Three Professional References

Name*
First Last

Phone*

Email*

Relationship*

Name*
First Last

Phone*

Email*

Relationship*

Name*
First Last

Phone*

Email*

Relationship*

DISCLOSURE STATEMENTS

1. Has any hospital or facility ever taken any action regarding your privileges, including but not limited to suspension, restriction, denial or revocation, or have you ever voluntarily resigned privileges in lieu of disciplinary actions?*
YES
NO

2. Have you ever had any negative action taken against you in connection with your license including but not limited to: revocation, suspension, probation, reprimand, censure, or restriction by any State licensing or other jurisdictional board?*
YES
NO

3. Has your authorization to practice in any jurisdiction ever been revoked, suspended, or subject to probation or any conditions or limitations?*
YES
NO

4. Have you ever voluntarily relinquished your license or membership or participation in any professional organization, including but not limited to any government sponsored health plan (e.g. Medicare and Medicaid), any third-party payor or other organization, in lieu of disciplinary action?*
YES
NO

5. Have you ever been censured by a professional association or society?*
YES
NO

6. Have you ever had action taken against you by any third-party payor, insurance company or HMO, including but not limited to Medicare and Medicaid, for inappropriate utilization of medical resources?*
YES
NO

7. Have you ever had a contract with Medicare or Medicaid that was restricted, provisional, revoked, excluded, or terminated and/or have you ever been mandated or agreed to pay civil fines under Medicare or Medicaid?*
YES
NO

8. Has your participation in any insurance carrier sponsored program been suspended or revoked? If “Yes”, please provide details on a separate sheet of paper.*
YES
NO

9. Do you have any misdemeanor or felony charges currently pending, or have you ever been convicted of a felony or misdemeanor other than a minor traffic violation?*
YES
NO

10. Have any malpractice suits, arbitrations or other proceedings ever been instituted against you? If “Yes,” please provide details on a separate sheet of paper including: when each action or proceeding was instituted and the status or outcome of each including the date and amount of any judgment, adverse decision or settlement, together with copies of the same. Include the name, address and policy number of insurance carrier if different from current policy.*
YES
NO

11. Has your professional liability insurance ever been refused, canceled or not renewed?*
YES
NO

12. Have you ever had a non-professional relationship with a client or former client that was sexual in nature, or was otherwise in violation of any ethical rules of your profession?*
YES
NO

13. Are you now or have you ever been an active or habitual user of any mind or mood altering substance, including but not limited to alcohol, narcotics, barbiturates, hypnotics, amphetamines, cocaine, benzodiazepines, or other controlled or illegal substance?*
YES
NO

14. Do you have any physical or mental health condition, treated or untreated, which even with accommodation would in any way impair your ability to practice to the fullest extent of your licensure and qualifications or in any way poses a risk of harm to your clients?*
YES
NO

Attestation and Release

I hereby submit this application for participation with Espyr. I understand that this application will be reviewed based on the information I have provided herein. I understand and agree that the certifications, authorizations and other provisions contained herein shall remain in force for so long as this application is pending and, if accepted for participation, for so long as my participating Provider agreement with Espyr remains in force. I understand and consent that Espyr has sole authority to accept or deny my application, as a participating Provider, and that I will not appeal a denial of my application. If Espyr does not credential me as a Provider, I agree not to initiate legal action in response to such determination. I hereby certify that the information contained herein is correct, accurate and complete to the best of my knowledge and belief. I understand that misrepresentations or omissions from this application may be cause for denial or dismissal from Espyr’s Provider Network, now or in the future. I agree to promptly notify Espyr if there are any material changes in the information provided, whether prior to or after my acceptance as an Espyr participating Provider. By applying for participation in the Espyr Provider Network, I hereby authorize any hospital, agency or group practice, other clinical employer, professional society, malpractice carrier, or other agency or organization with information regarding my credentials to release, furnish copies, or give details of my professional credentials and qualifications related to my clinical practice, competence and qualifications, including my moral and ethical qualifications. I hereby release from liability any and all individuals and organizations that, in good faith and without malice, provide information to Espyr for the purpose of evaluating this application and release Espyr from liability for its use of the information it gathers in the application process. A photocopy of this permission will be as valid as the original. This authorization to obtain confidential information about me remains in effect until I notify Espyr otherwise in writing, or am no longer an Espyr participating Provider.

Name of Applicant*
First Last

Signature of Applicant*

Date Signed*
MM slash DD slash YYYY

Questions about this application? Please call our Provider Relations Department at 800-522-1073 between 8:30am-5:00pm Eastern time, Mon. - Fri.