Behavioral Health Special Skills and Training Updates eForm

Please complete the following information to update the special populations served, attributes and modalities of care, and areas of expertise for a participating Behavioral Health provider.

Effective Date*

Group/Entity NPI*

Group/Entity Name*

Group/Entity TIN*

Provider NPI*

Provider Name*

Special Populations Served*

Check all that apply

Attributes and Modalities of Care*

Check all that apply

Areas of Expertise*

Check all that apply

Every Child, Every Family: Permanency Care Distinction?*

Yes
No

Please attach all relevant documentation and certificate(s) to confirm provider has completed training for this distinction.*

Drop files here or

Accepted file types: pdf, doc, docx, Max. file size: 12 MB.

Administrative Information

Office Contact Name*

Office Contact Email Address*

Details for the Person Submitting the Form

Name*

Title*

Phone #*

Practice Fax #*

Email*

Date*

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