CPAN/PeriPAN Practice Participation Agreement

The Child Psychiatry Access Network (CPAN) and Perinatal Psychiatry Access Network (PeriPAN) are programs funded through the Texas Legislature and designed to improve access to child/perinatal psychiatry consultation and mental health. Please fill out this survey if you are a primary care physician interested in registering for CPAN/PeriPAN.

Welcome

Please fill in the fields below.

Your Name

Your Title

NPI #

Your Email

Phone

Supervisor Name (if physician, type "N/A")

Do you provide primary care services to children?

Do you serve perinatal patients?

How did you hear about CPAN/PeriPAN?

Clinical Practice

Complete the following fields for your main clinical practice.

Practice Name

Name of Practice Medical Director/ Lead Physician

Medical Director or Lead Physician Email

Name of Office Manager

Office Manager Email

Street Address (Main Location)

Building or Office Number

City

ZIP

County

ACO or Physician Org

Is your clinic part of a larger organization? If so, please provide the name of your organization.

Contact Info

We will follow up directly with your preferred contact for your clinic. Please provide their information below.

Preferred Contact

Contact's Name

Contact's Email

Phone

FAX

CPAN/PeriPAN Participation

Please provide an estimate of the number of sites and providers from your practice who would participate in CPAN/PeriPAN.

Number of Sites

Number of Physicians

Number of APN/PA/Other Providers

Enrollment in CPAN/PeriPAN

By enrolling in the CPAN or PeriPAN Programs, primary care providers will be provided with the following:

• Child and Adolescent/Perinatal Psychiatry Continuing Medical Education (live and webinar)

• Access to Child and Adolescent/Perinatal Psychiatry Consultants within 30 min via telephone during normal business hours (initial and ongoing consultations are provided) - these are provider to providers consultations

• CPAN/PeriPAN website access (includes educational material)

• Assistance with psychiatry and related referrals by enrolling in the CPAN/PeriPAN Programs:

• I/We agree to participate in the CPAN/PeriPAN Program with the following Regional Team

• I/We agree to, when possible, participate in CPAN/PeriPAN consultation, training and educational opportunities.

• I/We agree to inform patients that we may engage the CPAN/PeriPAN program on their behalf and will share health information with the program unless the patient declines the CPAN/PeriPAN services.

• I/We agree to complete periodic satisfaction surveys.

• I/We agree to continue to manage behavioral health care of appropriate cases for the primary care setting following consultation with the team.

• Consultants from the Dell Medical School at The University of Texas at Austin (“DMS”) adhere to mandatory reporting laws in the services provided.

Acknowledgement

Next Steps

We will reach out to your preferred contact to register your providers. If you have additional questions or specific information you wish to share at this time, please enter below or contact us directly: 1-888-901-2726 / CPAN: cpan@austin.utexas.edu / PeriPAN: peripan@austin.utexas.edu

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