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First Responder Network Provider Application (Contractor)

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FRH is looking to expand our network of clinicians who work with our first responders and their families.  We are looking for experienced providers who are committed to serving the specific needs of this vital workforce. Thanks so much for taking the time to apply for our clinical network contract provider!  

Before we begin, here is some information that is required to complete our application:
  • Your resume
  • Your W9
  • Copy of your malpractice policy (Required $1M/incident $3M cumulative)
  • Your NPI number
  • Your group NPI (if applicable)
  • CAQH (if you have one)
Note: The NPI is a 10-digit number developed by the US Department of Health and Human Services, that will be used to identify you to your health care partners, including all payers, in all HIPAA standard transactions. If you do not have an NPI use this link to apply.

Let's begin!


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



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

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

Mailing Address






Billing Address





Practice Location(s)









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


Format: MM/DD/YYYY






Please click the link at bottom right to add another license.


Note: First Responder Health does not discriminate on the basis of race, color, sex or national origin.  Please be aware that the information below is beneficial to our first responders as some may feel more comfortable with a provider with specific characteristics.





We realize you may have other areas of expertise, but have limited these to those related to First Responders.













Experience with First Responders 

Acronym help:
CISD = Critical Incident Stress Debriefing



Enter 0 if none


Training Experience

Acronym help:
ICISF = International Critical Incident Stress Foundation
CISM = Critical Incident Stress Management












Attachments


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

Counseling Preferences






Please enter today's date, or a future date only.

Insurance






Professional Liability













**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.

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.


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