Mental Health Provider Enrollment Form

Name(Required)

First Last

Email(Required)

Phone(Required)

Agency/Business Name(Required)

Physical Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address(Required)

Street Address Address Line 2 City State ZIP Code

Phone Number(Required)

Fax Phone

Tax ID Number(Required)

Agency Contact Person and Phone Number(Required)

Provider's Supervisor and Phone Number(Required)

Degree(s) and year completed(Required)

Date(Required)

Is the provider licensed in the State of Idaho(Required)

Provider's Idaho License Number(Required)

Expiration Date(Required)

Is the provider licensed in the other dates(Required)

If Yes, what states?

Has the provider's license ever been revoked or suspended?(Required)

If Yes, why?

Provider's NPI Number(Required)

Does the provider hold profession liability insurance?(Required)

Insurance Provider(Required)

Expiration Date of Insurance Policy(Required)

Policy Coverage Amounts(Required)

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