Independent Practitioner or Group Practice

Are services provided through telehealth, in-perso

Community Behavioral Health (CBH) is soliciting applications for qualified independent practitioners and group practices.

Is the person completing this application the person applying to be credentialed in the CBH network.

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

Please indicate whether you are applying as an independent practitioner, or as part of a group practice comprised of staff of the same discipline and licensure.

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If a group practice, please enter the name of your group practice.

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Enrollment in Medicaid requires that practitioners adhere to the PA Code relevant to their licensing entities.

For social workers, marriage and family therapists, and professional counselors, the state regulations can be found here. For psychologists, the state regulations can be found here.

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Yes

No

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

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Please attach a copy of your license

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