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!

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

Business Phone

Mobile Phone

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 Name

Practice Street Address

Suite #

City

State

Zip Code

Does this office have handicap access?

YesNo

This is a group practice

Group NPI

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

Provider Profile Information

Licensure

Select your license type

State of issue

If you are licensed in another state AND/OR have an additional license, please click the link below to add another license.

Individual NPI

Date of Birth

Format: MM/DD/YYYY

CAQH Number (if you have one)

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.

Gender

Sexual Orientation

Race/Cultural identity (select all that apply)

American Indian or Alaska Native	Asian
Black or African American	Hispanic or Latino
Native Hawaiian or Other Pacific Islander	White
Some Other Race

Select your areas of expertise as it relates to First Responders (FRs) and/or their families:

Abuse (Sexual/Physical/Emotional)	Addictive Disorders (non-substance abuse)
Adoption	Alcohol/Substance Use Disorders
Anger Management	Anxiety Disorders
Codependency	Couple/Marital
Depression	Developmental, Education and Learning Disabilities
Domestic Abuse	Eating Disorders
EMDR	Gambling
Grief	Health Medical Issues
Neurocognitive Disorders	Parenting
Self-Harming	Sexual Problems
Sleep or Insomnia	Stress
Suicidal Ideation	Testing and Evaluation
Trauma and PTSD	Work Issues

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

Please list any certifications you hold or specific training that pertains to your expertise

Select the populations you work with:

Adults	Adolescents	Children Age 6-12
Children Age 0-5	Hearing Impaired	Visually Impaired
Faith Based	Multicultural	LGBTQIA+
Communications	Corrections	Dispatch
Fire Service	Health Care	Law Enforcement
Military	Post Retirement	Probations
Public Safety	Veterans	Other

For children/adolescents, is there anything specific about their

first appointment?

Other first appointment requirement for minors

Which client types do you work with?

Individuals

Couples

Families

Which treatment modalities do you provide?

Accelerated Resolution Therapy (A.R.T)	Adlerian
Art Therapy	Behavior Modification
Brainspotting	Career Job Coaching
Cognitive Behavioral (CBT)	Couples Therapy
Dialectical Behavior (DBT)	Eclectic
Existential	Family Systems
Forensic Psychology	Gestalt
Gottman Method	Jungian
Mediation/Conflict Resolution	Mindfulness-Based (MBCT)
Motivational Interviewing	Neurofeedback
Organizational Training	Play Therapy
Positive Psychology	Psychoanalytic
Psychological Testing and Evaulation	Rational Emotive Behavior (REBT)
Solution Focused Brief (SFBT)	Strength-Based
Trauma Focused	Other

Other Treatment Modality

Do you have experience as a clinical supervisor?

YesNo

Have you been licensed for over two years?

YesNo

How many years have you been providing clinical supervision?

How many supervisees do you current have?

Counseling language other than English

Spanish	American Sign Language (ASL)
Arabic	Chinese (simplified)
Chinese (traditional)	Croatian
Dutch	Farsi
Filipino	French
German	Greek
Hebrew	Hindi
Hungarian	Italian
Japanese	Korean
Laotian	Latvian
Nigerian	Polish
Portuguese	Romanian
Russian	Thai
Urdu	Vietnamese
Yiddish	Other

Other Language

Experience with First Responders

Acronym help:
CISD = Critical Incident Stress Debriefing

Have you worked with first responders in the past 5 years?

YesNo

Have you completed Peer Support Training?

YesNo

How many CISDs have you conducted in the past 5 years?

Enter 0 if none

List your critical incident activities

Please note any other personal experience you may have with first responders.

Training Experience

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

Do you have any experience providing training?

YesNo

Have you provided training to First Responders?

YesNo

Are you interested in becoming a trainer with First Responder Health?

YesNo

List training topics you have presented

How do you prefer to deliver training?

OnlineIn PersonOnline and In Person

Have you completed an ICISF CISM course?

YesNo

Do you have any experience with curriculum development?

YesNo

Do you have any experience leading or working at retreats?

YesNo

What is your experience in Education in general?

Are you willing to travel?

YesNo

How many miles are you willing to travel?

By which means?

Car onlyPlaneAny means

Attachments

Attach your resume

Attach Malpractice documentation

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

Attach your signed W9

Counseling Preferences

How do you prefer to treat clients?

Telehealth Platform

Which video application(s) do you use?

Doxy	Google Meet	Join.me
MeetMe	MS Teams	Skype
Webex	Zoom	Other

Other video platform

Would you be willing to use our scheduling software?

When are you available to start?

What is the best way to deliver a referral to you?

Insurance

Which health care contracts do you work with?

1st Health	Aetna
Anthem/Blue Cross Blue Shield	Beacon/Carelon
Cigna	Healthnet
Holman Group	HMC Healthworks
Humana	Kaiser
Magellan	Multiplan
Optum	Other
None

Other Health Plan

Which EAP providers do you work with, if any?

WPO: Work Place Options

Cigna

Magellan

Other EAP Provider

Which Workers Comp contracts do you work with, if any?

Carelon

Sedgwick

Corvel

Other Workers Comp

Other Workers Comp contract

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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