Mental Health Outpatient Provider Application

Community Behavioral Health (CBH) is soliciting applications for Mental Health Outpatient providers. At this time, Providers who do not have a physical site in Philadelphia, or are offering only telehealth will not be considered. Interested qualified applicants should complete the below application. CBH will review all submissions and will contact qualified applicants.

Person Completing Form

Name and title of person completing form.

Provider Name

Please include the name of the organization/facility interested in joining the CBH provider network

Contact Email

Please enter the email of the point person responsible for credentialing. Follow-up regarding next steps will be emailed to this address.

Are you enrolled in Pennsylvania Medicaid?

Are you currently enrolled in PROMISe as a mental health outpatient provider?

Were you previously an in-network CBH Provider?

Guidelines & Performance Standards

Do you agree to adhere to CBH’s Clinical Practice Guidelines and Performance Standards included in the CBH Provider Manual?