Acute Inpatient Psychiatry (AIP) Provider Application

Acute Inpatient Psychiatry (AIP) Provider Application

Community Behavioral Health (CBH) is seeking providers who are currently operational and can provide Acute Inpatient Psychiatry (AIP) to the Medicaid recipients of Philadelphia. CBH is seeking AIP providers that can provide 24/7 care to children and/or adult populations. The AIPs must be located in or near Philadelphia. Hospital-based and free-standing AIPs will be considered. Interested qualified applicants should complete the below application. CBH will review all submissions and will contact qualified applicants.

Person Completing Form*

Please include your name and title.

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 with the appropriate Provider Type and Specialty?

Select

Were you previously an in-Network CBH provider?

Select or enter value

Why did you previously leave the CBH network?

Guidelines & Performance Standards*

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

Select

License*

Please attach a copy of your AIP license

Drag and drop files here or

Note/Comments

Send me a copy of my responses

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