ࡱ> %` >bjbj"x"x @@5F F F F F F F T <<<=?d o?" HJIJIJI~J$OQH$!h F R~J~JRR F F JIJI4)YYYRF JIF JIYRYY0F F fJI? `{_<STJ$<?0on)@UN)Hf)F fDRRYRRRRR Y^RRRoRRRR $d $ F F F F F F  CIGNA Practitioner Screening Form For Behavioral Health Practitioners Thank you for your interest in becoming a provider for CIGNAs behavioral provider network. To determine if you meet minimum credentialing requirements, please complete the following Provider Screening Form and return it to fax # 860-735-7683 Please type directly on this form or print the form and complete using legible handwriting. If CIGNA extends credentialing to you, the information outlined on the form will be used to create your provider profile, including locations and specialties, to assist in the member referral process. Please complete all sections of the screening form. Incomplete forms will not be considered. Please do not include any additional paperwork. This form does not constitute an offer to join CIGNA's behavioral provider network and is for screening purposes only. Applicant Name:  FORMTEXT       FORMTEXT        FORMTEXT       Degree:  FORMTEXT       License Type:  FORMTEXT       First Middle Initial Last SSN:  FORMTEXT       CAQH # (if known):  FORMTEXT       NPI # (if known):  FORMTEXT       Gender:  FORMCHECKBOX M  FORMCHECKBOX F DOB:  FORMTEXT       E-mail address:  FORMTEXT       Do you have at least two years post-independent licensure experience?  FORMCHECKBOX Yes  FORMCHECKBOX No Are you in practice with a CIGNA contracted PHYSICIAN or other PRESCRIBING provider?  FORMCHECKBOX Yes  FORMCHECKBOX No If yes, please indicate that provider s name:  FORMTEXT        FORMTEXT       Name Phone Professional Liability Insurance Limits: Occurrence  FORMTEXT       Aggregate  FORMTEXT       Mailing Address (1 mailing address only for correspondence, including credentialing materials):  FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT        FORMTEXT       Street Address/PO Box Suite City State Zip Code Service Location Service Location Street:  FORMTEXT       Suite:  FORMTEXT       Street:  FORMTEXT       Suite:  FORMTEXT       City/State:  FORMTEXT       Zip:  FORMTEXT       City/State:  FORMTEXT       Zip:  FORMTEXT       County:  FORMTEXT       Is office in your home?  FORMCHECKBOX  Y  FORMCHECKBOX  N County:  FORMTEXT       Is office in your home?  FORMCHECKBOX  Y  FORMCHECKBOX  N Appts/Intake Phone:  FORMTEXT       Appts/Intake Phone:  FORMTEXT       Business office Phone:  FORMTEXT       Business office Phone:  FORMTEXT       Fax:  FORMTEXT       Fax:  FORMTEXT       Crisis Phone:  FORMTEXT       Crisis Phone:  FORMTEXT       Other: Cell  FORMCHECKBOX  Pager  FORMCHECKBOX  : Other: Cell  FORMCHECKBOX  Pager  FORMCHECKBOX  : **Clinical Hours Worked Per Week**(required)  FORMTEXT       **Clinical Hours Worked Per Week**(required)  FORMTEXT       TAXPAYER & BILLING INFORMATION: Please list all Tax ID # s to be included in your profile: Tax ID #:  FORMTEXT       Tax ID #:  FORMTEXT       Taxpayer Name (as registered with the IRS): Taxpayer Name (as registered with the IRS):  FORMTEXT        FORMTEXT       Street:  FORMTEXT       Suite:  FORMTEXT       Street:  FORMTEXT       Suite:  FORMTEXT       City/State:  FORMTEXT       Zip:  FORMTEXT       City/State:  FORMTEXT       Zip:  FORMTEXT       Billing Phone:  FORMTEXT       Billing Phone:  FORMTEXT       **Please copy this page if more space is required** %ADVANCED PRACTICE NURSES/NURSE PRACTITIONERS (required)  FORMCHECKBOX Yes  FORMCHECKBOX No Do you provide medication management?  FORMCHECKBOX Yes  FORMCHECKBOX No Do you have prescriptive authority?  FORMCHECKBOX Yes  FORMCHECKBOX No Do you have your own DEA #?  FORMCHECKBOX Yes  FORMCHECKBOX No Are you able to prescribe a full range of medications (including controlled substances)? ***************************************************************************************************** %PHYSICIAN ASSISTANTS (required): Please indicate the name and phone number for your supervising Physician: Name:  FORMTEXT       Phone:  FORMTEXT       **The supervising physician must be participating in CIGNA s behavioral provider network for a PA-C to be credentialed** **************************************************************************************************** %PHYSICIANS (required) All physicians, please indicate the scope of your practice:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you completed a residency program in Psychiatry?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you Board Certified by the American Board of Psychiatry and Neurology?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you Board Certified in a Psychiatric sub-specialty (e.g. Child & Adolescent, Geriatric)? If yes, please indicate which subspecialty:  FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you Board Certified in any other specialty? If yes, which Board?  FORMTEXT        FORMCHECKBOX  Yes  FORMCHECKBOX  No Are you certified by the American Society of Addiction Medicine (ASAM) as an addictionologist?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you provide outpatient medication management services?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Do you provide inpatient attending or consult services, or other facility-based services? If yes, facility name?  FORMTEXT       ***************************************************************************************************** %ALL PROVIDERS MUST COMPLETE THE FOLLOWING SPECIALTY NETWORKS: To participate in CIGNA's behavioral health Specialty Networks, please review the criteria required, as outlined below. Please note: provider attestation is required and you are subject to a specialty documentation audit. DIAGNOSTIC TESTING  FORMCHECKBOX  Neuropsychological Testing: Member of the American Board of Clinical Neuropsychology or the American Board of Professional Neuropsychology OR each of the following: Completion of courses in Neuropsychology including: neuroanatomy, neuropsychological testing, neuropathology or neuropharmacology Completion of internship, fellowship, or practicum in Neuropsychological Assessment at an accredited institution Two years of supervised professional experience in Neuropsychological Assessment **To claim a specialty in the following designated areas, you must meet one or more of the following conditions: Certification by a nationally recognized certifying organization. An internship, fellowship, or formal training program in an accredited institution focusing on treatment of one of the designated disorders or groups of patients or use of one of the designated treatment modalities. An accumulation of continuing education units or course work focused on current treatment of one of the designated disorders or groups of patients or use of one of the designated treatment modalities. Significant work experience focused on current treatment of one of the designated disorders or groups of patients. The depth and breadth of experience must demonstrate that you have gained the knowledge and skill to be considered a specialist. PATIENT AGE GROUPS  FORMCHECKBOX  Geriatric (ages 65 or older)  FORMCHECKBOX  Adult (ages 18-64)  FORMCHECKBOX  Adolescent (ages 13-17)  FORMCHECKBOX  Child (ages 6-12)  FORMCHECKBOX  Child (ages 1-5) DISORDERS  FORMCHECKBOX  Alcohol/Substance Abuse/ Dual Dx  FORMCHECKBOX  Autism/Developmental Disorder  FORMCHECKBOX  Eating Disorder  FORMCHECKBOX  Pain Management  FORMCHECKBOX  Sexual Disorders  FORMCHECKBOX  Sexual Offenders TREATMENT MODALITIES  FORMCHECKBOX  Dialectic Behavioral Therapy (DBT) Certification Reqd  FORMCHECKBOX  EMDR--Level 2 Certification Reqd  FORMCHECKBOX  Outpatient Treatment with Buprenorphine (Physicians only-Please include documentation of DEA waiver) SUBSTANCE ABUSE PROFESSIONALS (SAP) per DOT requirements :  FORMCHECKBOX  Yes  FORMCHECKBOX  No Have you met the Department of Transportation (DOT) requirements (effective 1.1.2004) for providing SAP services, which include successfully completing a qualification training course recognized by the DOT and satisfactorily completing a post training examination administered by a nationally recognized professional or training organization? 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h4&kCJOJQJ^JaJ#hE-h4&k>*CJOJQJ^JaJ/j:hE-h4&kCJOJQJU^JaJ/j:hE-h4&kCJOJQJU^JaJ hE-h4&kCJOJQJ^JaJ)jhE-h4&kCJOJQJU^JaJh4&k5CJOJQJ\^Jh4&k5CJOJQJ\^Jh4&k5CJOJQJ\^Jh4&k5>*CJOJQJ\^J)hE-h.]5>*CJOJQJ\^JaJ==N>4?? δpt@Bs `' dh] dL  !5$7$8$9DH$ (#-DM  -DM  -DM  0*-DM  0*-DM ^`gd  `' P>l>n>p>~>>>>>Z?\?p?r?t?~??????xZ9x@jhE-h4&k>*B*CJOJQJU^JaJmHnHphu;j;hE-h4&k>*B*CJOJQJU^JaJph,hE-h4&k>*B*CJOJQJ^JaJph5jhE-h4&k>*B*CJOJQJU^JaJph/jr;hE-h4&kCJOJQJU^JaJ)jhE-h4&kCJOJQJU^JaJ/j:hE-h4&kCJOJQJU^JaJ hE-h4&kCJOJQJ^JaJ????????@ ">@BPRnprδдw_/j6>hE-h4&kCJOJQJU^JaJ/j=hE-h4&kCJOJQJU^JaJ/jJ=hE-h4&kCJOJQJU^JaJU/j<hE-h4&kCJOJQJU^JaJ hE-h4&kCJOJQJ^JaJ)jhE-h4&kCJOJQJU^JaJ/j^<hE-h4&kCJOJQJU^JaJent Referrals?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Work Site Supervisory Training Sessions?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Critical Incident Response? CIR Training:  FORMCHECKBOX  Mitchell Model  FORMCHECKBOX  Miller Model  FORMCHECKBOX  Other:  FORMTEXT       LANGUAGES: Add l languages in which you are fluent in conducting therapy:  FORMTEXT       APPOINTMENT AVAILABILITY & CONSULTATIVE SERVICES:  FORMCHECKBOX  Appointments Evening: Available to see participants after 5 p.m. on weekdays.  FORMCHECKBOX  Appointments Weekend: Available to see participants on Saturdays and/or Sundays.  FORMCHECKBOX  Inpatient pre-discharge consultation non-MD : For Non-MDs only. Available to do on-site inpatient consultation; i.e. discharge planning and initiate a therapeutic relationship prior to discharge of participant.  FORMCHECKBOX  Intermediate Care Services: a level of intervention that provides precautionary and preventive care to a participant who presents with a level of acuity that, if not addressed within 48-hours, could escalate to a higher level of care. AREAS OF CLINICAL EXPERTISE: Indicate only the areas which are the primary focus of your practice.  FORMCHECKBOX  ADHD/ADD  FORMCHECKBOX  Domestic Violence  FORMCHECKBOX  Marital/Couples Therapy  FORMCHECKBOX  Adoption Issues  FORMCHECKBOX  EAP: Assessment/Referral  FORMCHECKBOX  Medical Issues/Illness  FORMCHECKBOX  AIDS/HIV  FORMCHECKBOX  Faith Based Counseling  FORMCHECKBOX  Minority Issues  FORMCHECKBOX  Anger Management  FORMCHECKBOX  Family Therapy  FORMCHECKBOX  Obsessive Compulsive D/O  FORMCHECKBOX  Anxiety Disorder  FORMCHECKBOX  Fertility Issues  FORMCHECKBOX  Panic Disorder  FORMCHECKBOX  Bipolar Disorder  FORMCHECKBOX  Gambling Addictions  FORMCHECKBOX  Phobias  FORMCHECKBOX  Borderline Personality Disorder  FORMCHECKBOX  Gay/Lesbian Issues  FORMCHECKBOX  Psychological Testing  FORMCHECKBOX  Conduct/Disruptive Disorder  FORMCHECKBOX  Gender Identity  FORMCHECKBOX  Psychotic Disorders  FORMCHECKBOX  Depression  FORMCHECKBOX  Grief/Loss  FORMCHECKBOX  PTSD  FORMCHECKBOX  Dissociative Disorder  FORMCHECKBOX  Home Visits  FORMCHECKBOX  Sexual Abuse/Incest ************************************************************************************************************ ADDITIONAL INFORMATION: If CIGNA extends credentialing to you, the Participating Provider Agreement will include all lines of business. In addition, Individual Participating Provider Agreements cover your services at all practice locations and Tax ID# s  please include all practice sites and Tax ID# s on Page 1 of the Provider Screening Form to avoid claims problems. PROVIDER ATTESTATION I hereby certify and attest that all of the information above is true and accurate, and misstatement or omission may result in denial of application with or without appeal. If credentialed as a CIGNA behavioral network provider, I will cooperate during a specialty documentation audit, if requested, to verify that I meet the outlined criteria for participation in the Specialty Network(s). I understand that any information provided pursuant to this attestation that is subsequently found to be untrue and/or incorrect could result in my termination from CIGNA s behavioral provider network. A copy of this attestation shall have the same force and effect as the signed original. __ FORMTEXT      _____________________________________________ _ FORMTEXT      ___________________________ PROVIDER SIGNATURE DATE  CIGNA and the  Tree of Life logo are registered service marks of CIGNA Intellectual Property, Inc., licensed for use by CIGNA Corporation and its operating subsidiaries. All products and services are provided exclusively by such operating subsidiaries and not by CIGNA Corporation. Such operating subsidiaries include International Rehabilitation Associates, Inc. (Intracorp), CIGNA Behavioral Health, Inc., vielife Limited, Connecticut General Life Insurance Company and HMO subsidiaries of CIGNA Health Corporation.     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