【Yes|Yes,Illsharemywindfallwithaneighborinneed】1、Community Healthlinka Member of UMass Memorial Health CareCommunity Healtlilink Inc.CREDENTIALING PROFILE FORMCHL is responsible for ciedentialnig all providers. Please complete the attached profile and retiim it to Human Resources along witli all o tlie following that are applicable: A copy of all。

2、wild licenses A copy of your lughest degree A copy of any applications 01 letters of acceptance from tlie Managed Care panels A copy of your resume or curriculum vitae Medicare Number National Provider Identification (NPI) number. Cluld and Adolescent Needs and Streiigtlis Assessment (CANS) certific 。

3、ate numberIf you are a licensed social worker (LCSXK： LICSVC)a licensed psychologist, or an advanced practice nurse (RNCS) and anticipate seemg Medicare cEents, please ask Human Resources for a Medicare Application. I you already have a Medicare ID number, please ask for an assignment form.If you wi 。

4、ll be working witli clulduen, you must be certified to adniHiister Tlie Child and Adolescent Needs and Strengtlis tool (CANS). If you are not certified, please talk to your supenrisor about becoming certified. I you are certified, please attach a copy of your certification.If you do not currently ha 。

5、te a National Provider Identifiei number (NPI), please ask Human Resources for tlie information sheet on applymg.Tliank you in advance, and welcome to CHL!Reused 6/27/12Page 2 of 6CREDENTIALING PROFILE FORMSection I： PERSONAL INFORMATIONName:FirstXiddleHome Address:Home Telephone: () SS#:-Birth Date 。

6、:Place of Butli:Citizenslup:If not an American citizen, status and visa number:Program(s)/Site(s) tliat you have been lured for:Job Title:Section II: EDUCATION INFORMATIONInclude Undeugi次duoteGi:久chiQte, and PostgraduQte Education (attach copy of highest degree)School Name and Mailing AddressDegree。

7、AwardedDates AttendedGraduation DateSection III: LICENSUREPlease list q!1 cunrent professional licenses 俎xl attach o copyStateLicense TypeNumberOriginally IssuedExpiration DateYears o hill time experience smce obtaiiuiig lughest degree:Years o superv丄soiy experience since obtaining lughest license:。

8、Number o people you have formally supervised:Please list any post pirofessionol licenses that ore no longer active.StateLicense TypeNumberOriginally IssuedExpiration DateSection IV: ADMITTING PRIVILEGESPhysicmns/psychologists list hospitals/health caue facilities fou which you hove odmitting pnxaleg 。

9、es.Facility NameMailing AddressCity and StateTelephoneSection V： REGISTRATIONS AND CERTIFICATIONSPlease mcUcote any uegistiQtiorLS and ceuti&c久tion that you possess and Qtuch copies.Type ofRegistration/CertificationRegistration/ Certificate #Date IssuedExpiration DateCANSFederal DEA #State Controlle 。

10、d Substance #Universal Personal Identification # (PIN)Medicare #NPI#NAOthersSection VI： PANELING/CREDENTIALINGPlease list Managed Care panels on winch you hae served. Submit any copies of applications or letters of acceptance from tlie Managed Care panels that you have.Managed Care CompanyDate of Pa 。

11、nelingPractice Name /LocationCurrent/ Expired?Section VII： LANGUAGES SPOKENPlease mcUcQte hnguages spoken and degree of proficiency.Language SpokenDegree ofProficiencyHave you provided treatment in this language?Section VIII: QUESTIONNAIREIf you answer yes to any of die questions in section 8, you m 。

12、ust provide an explanation o each occurrence. Additional Hifbimation may be leqinred as indicated 111 certain questions.1. Have tlieie ever been any actions agauist or investigations relatnig to your professional license(s) m any jurisdiction?Yes NonN/A 2. Have you ever voluntarilv or mvoluntarilv s 。

13、urrendered vouiJJJ9license?Yes NonN/A 3. Have tlieie ever been any actions agauist or investigations relatuig to youi hospital, HMO and/or health/managed care plan privileges?Yes NoQN/A 4. Have you ever voluntarily oi mvoluntarily suriendered hospital, HMO and/or healtli/managed care plan privileges 。

14、?Yes NonN/A 5. Have you ever been named in any malpractice action?Yes No 口6. Does you current Lability malpractice insurance coverage exclude any specific procedures?Yes N 。
口n/a 7. Has youi professional liability msurance coverage ever been denied, suspended, restricted, limited, modified, cancelled。

15、or not renewed by tlie action of any insurance company?Yes Non8. Have tliere ever been any actions agauist or investigations relatuig to your DEA registration and/or CDS certification or have you ever voluntaiil or mvoluntarily suriendered your DEA registration and/or CDS certification?Yes Nonn/a 9. 。

16、 Have you ever been convicted of a felony, including, but not limited to, fraud, narcotics, or crimes mvolvmg cluldren? (Misdemeanois do not need to be reported). Tins statement is answered under tlie penalty o perjurysubject to applicable Federal pumshnient for peujuiy. If yes, please mclude tlie d 。

17、isposition of the arrest oi charge and explain all such occurrences m an attaclunent Yes Non10. Have you ever been sanctioned oi otherwise disciplniecl by a piofessional oigamzation/association?Yes Nonn/a 11. Have vou ever vohuitarily or iiHvoluntaiilv suirendeied memberslup m a professional oigaiuz 。

18、ation/association?Yes Non12. Has tlieie ever been any discipkiiary action, suspension, probation, formal repmiiancl or request to voluntarily or HHvoluntarily resign during 5rour education, mternslup, residency, fellowship, preceptoislup, oi additional applicable trauiHig?Yes N 。
口13. Has tlieie been。

19、any action against oi investigation relating to youi board certification (e.g. medical professional board/society) or have you voluntarily or uivoluntarily surrendered any board certification?Yes NoQN/A 14. Has an adverse action been filed against you or have you received any discipluiary procedures 。

20、 regaidiiig your participation in any private, state, or federal insurance program including Office of Personnel ， Medicare, Medicaid or TRICARE?Yes NonN/A 15. Is there mytliing that would prevent you from being able to competently peifoim essential job-ielated Ruictions without risk to client safety。

21、or healtli, witli or without reasonable accommodation?Yes Non16. Are you currently usmg any illegal substances oi are you chemically dependent on alcohol, drugs, or illegal substances?Yes NonSection IX： PROFESSIONAL TRAINING ATTENDANCE CPR CertificationFirst AidOther:Training Attended in the last ye 。

22、ar(include subject, presenter, organization or individual, and month/yearSection X: SPECIALTIESFrom tlie list below, identify ant specialty area where you have traimng 01 expertise:_ BiofeedbackBorderline Personalia* TraitsI Bne TlierapyzGenetic Tlierapy Geriatric ServicesGrief BereavementI | Cluld。

23、TherapyHead TraumaCluonic PainHearing ImpairmentCluonic Ternmial IllnessHIV/AIDSI | Alcohol/Dmg Counseling Anxiety Disorders ADD-ADHDFamily Violencej Forensics Gay/Lesbiaii/Bisexual/Tians.| U Psychiatric EvaluationsJ Psychological testingi Psychopliarmacolog- Relapse Pre-ention: SA Scliizoplueiua Sc 。

24、hool Related Problems Sexual Abuse Severe/Persistent Mental Illness Sexual DysfunctionAdoptionEating DisordersAdjustment DisordersECT匚Adolescent Behavior disorderszEthnic/Cultural IssuesAffective DisordersFanulv TlierapvPersonality- DisorderPhysical Abuse Plivsicallv disabledJJPost Traumatic Stress。

25、disorder；DBT TreatmentDual Diagnosis: MH/IRess Servicesrl Sexual Offenders| Sleep DisordersI j Step Blended Families_ Dual Diagnosis: w/ SAMviltiple Personality Disorder Nevxropsychological TestingStress ManagementWomens Issuesee Assistance Work IssuesEarly Interventionsessive Compulsive Disorderj P 。

26、aine Phobia| | Other: j Other:Section XI: VERIFICATIONMy signature below indicates that all of the mformation provided above is accurate and complete. My signature also mdicates my consent for Community Healtliliiik to obtain my academic records, state licensure records, and ledicaie/Medicaid records to ensure that tlie mfoimation provided is accurate, my licensure is in good standmg, and that I have not been excluded to participate in any public or private insurance program.My typed name below shall have tlie same force and effect as my written signature.DateReused 6/27/12Page 8 of 6 。

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标题：Yes|Yes,Illsharemywindfallwithaneighborinneed