DEA EAP Network Single Case Agreement Application

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Thank you for your interest in The Counseling Team International DEA Network. We take every precaution to properly qualify providers for the network to ensure they meet the growing needs of our clients and that they will have a positive experience working with us.

QUALIFICATIONS

In Person Counseling

Master’s Degree or higher
Fully licensed in the state you provide services
Malpractice insurance in an amount of not less than one million dollars ($1,000,000) per occurrence and three million dollars ($3,000,000) per aggregate
Minimum of three years experience

Telehealth Counseling

All of the above, plus:

HIPAA-compliant video counseling platform
Business Associate Agreement from a platform verifying the platform is HIPAA compliant
Malpractice insurance that includes video counseling

CREDENTIALING

Credentialing is the process we use to verify your professional credentials in conjunction with our

criteria. Here’s what you need for a Single Case Agreement:

A copy of your license(s)
A copy of your malpractice insurance
Your W9 (a fillable W9 form may be downloaded at https://www.irs.gov/forms-pubs/about-form-w-9)

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First things first...are you a US citizen or an Alien authorized to work in the United States?

YesNo

Thank you for your interest. At this time we can only accept applications from providers who are authorized to work in the U.S.

Provider Contact Details

First Name

Last Name

Practice Name

Is this is a group practice?

Business Phone

Format: ###-###-####

Mobile Phone

Format: ###-###-####

Email Address

Mailing Address

Mailing Street Address

Suite #

Mailing City

Mailing State

Mailing Zip Code

My billing address is the same as my mailing address

YesNo

Billing Address

Billing Street

Suite #

Billing City

Billing State

Billing Zip Code

Practice Location(s)

My practice address is the same as my mailing address

YesNo

Practice Street Address

Suite #

City

State

Zip Code

Evening Hours

Weekend Hours

Is this an accessible location?

YesNo

If you have multiple practice locations, please click link at bottom right to add another location.

Provider Profile Information

Date of Birth

Format: MM/DD/YYYY

Sex

Licensure

Select your primary license type

State of issue

Upload a copy of your license.

Attachments

Attach malpractice documentation

NOTE: We require $1M per occurrence and $3M aggregate malpractice insurance.

Attach your signed W9

Professional Liability

Have you had any professional liability actions (pending, settled, arbitrated, mediated or litigated) within the past 10 years? If yes, provide information for each case at the bottom of the page.

YesNo

Has your professional liability coverage ever been canceled, restricted, declined or not renewed by the carrier based on your individual liability history?

YesNo

Has your license, registration or certification to practice in your profession, ever been voluntarily or involuntarily relinquished, denied, suspended, revoked, restricted, or have you ever been subject to a fine, reprimand, consent order, probation or any conditions or limitations by any state or professional licensing, registration or certification board?

YesNo

Have you ever been convicted of, pled guilty to, or pled nolo contendere to any felony?

YesNo

In the past ten years have you been convicted of, pled guilty to, or pled nolo contendere to any misdemeanor (excluding minor traffic violations) or been found liable or responsible for any civil offense that is reasonably related to your qualifications, competence, functions, or duties as a medical professional, or for fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?

YesNo

Have you ever been disciplined, excluded from, debarred, suspended, reprimanded, sanctioned, censured, disqualified or otherwise restricted in regard to participation in the Medicare or Medicaid program, or in regard to other federal or state governmental healthcare plans or programs?

YesNo

Have your clinical privileges or medical staff membership at any hospital or healthcare institution, voluntarily or involuntarily, ever been denied, suspended, revoked, restricted, denied renewal or subject to probationary or to other disciplinary conditions, or have proceedings toward any of those ends been instituted or recommended by any hospital or healthcare institution, medical staff or committee, or governing board?

YesNo

Have you ever been terminated for cause or not renewed for cause from participation, or been subject to any disciplinary action, by any managed care organizations (including HMOs, PPOs, or provider organizations such as IPAs, PHOs)?

YesNo

Are you currently the subject of an investigation by any hospital, licensing authority, DEA or CDS authorizing entities, education or training program, Medicare or Medicaid program, or any other private, federal or state health program or a defendant in any civil action that is reasonably related to your qualifications, competence, functions, or duties as a medical professional for alleged fraud, an act of violence, child abuse or a sexual offense or sexual misconduct?

YesNo

To your knowledge, has information pertaining to you ever been reported to the National Practitioner Data Bank or the former Healthcare Integrity and Protection Data Bank?

YesNo

Do you use any chemical substances that would in any way impair or limit your ability to practice and perform the functions of your job with reasonable skill and safety?

YesNo

Are you unable to perform the essential functions of a practitioner in your area of practice even with reasonable accommodation?

YesNo

Are you **currently engaged in the illegal use of drugs?

YesNo

**currently - means sufficiently recent to justify a reasonable belief that the use of drugs may have an ongoing impact on one's ability to practice medicine. It is not limited to the day of, or within a matter of days or weeks before the date of application, rather that it has occurred recently enough to indicate the individual is actively engaged in such conduct. "Illegal use of drugs'' refers to drugs whose possession or distribution is unlawful under the Controlled Substances Act, 21 U.S.C. § 812.22. It "does not include the use of a drug taken under supervision by a licensed healthcare professional, or other uses authorized by the Controlled Substances Act or other provision of Federal law." The term does include, however, the unlawful use of prescription-controlled substances.

Explanation(s)

If you answered 'Yes" to any of the questions in this section, please explain.

Attestation

By submitting this application, I hereby attest that all the information in this application is true and accurate to the best of my knowledge, and if I am not the provider, I am authorized to submit this information on their behalf. Provider agrees they shall maintain proficiency in all specialty areas selected on this application.

I understand that First Responder Health may require documentation to verify that the provider meets the criteria outlined in this application.

Submitter's Full Name

Submitter's Email

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