MENTAL HEALTH PROVIDER INFORMATION FORM

MENTAL HEALTH

PROVIDER INFORMATION FORM

PLEASE VERIFY THE ACCURACY OF YOUR DATA PRIOR TO SUBMISSION. IF THE INFORMATION IS INACCURATE, WE CANNOT PROCESS THE REQUEST. Most fields are MANDATORY; if not applicable, please enter N/A.

Kaiser Mental Health Access Standards*

Provider is able to meet the following access standard (Y/N):

Provider must agree to meeting the appt standards
Routine: Members with routine needs have their initial appointment within 10 business days of the referral date
Urgent: Members with urgent needs will be offered an initial appointment within 48 hours of the referral date.

Select

STOP! Unless you agree to the above access standards we cannot move your request to contract forward

Kaiser Permanente is currently seeking providers who have availability to take new Kaiser members only.

New Network Provider Assessment

Please answer the following questions regarding your appointment access and capacity, clinical model and practice management standards.

Continuity of Care*

Are you currently seeing any Kaiser Permanente Washington (KPWA) members?

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Provider Capacity*

Are you currently accepting new patients?

Select

Routine Appointment Access*

On average, what percentage of routine appointments are able to be scheduled within 10-days?

Select

Urgent Appointment Access*

On average, what percentage of urgent appointments are able to be scheduled within the next-day (24-hours)?

Select

Feedback Informed Care*

Please indicate how different clinical assessment tools (PHQ, GAD, CSSRS) are utilized within your practice.

Select

Clinical Practice and Treatment Plan Guidelines*

Please indicate what best describes clinical practice and treatment plan guidelines within your practice.

Select

Service Administration*

Do you offer Telehealth/Telemedicine Services?

Select

Age Range*

Are you currently accepting only adult patients, pediatric patients, geriatric patients, or all patients across all age ranges?

Select

Acuity Levels*

Please indicate what levels of care are treated within your practice.

Select

Tax ID: No dashes.*

Due to this being a web-based form, if your Tax ID is your social Security #, please 000000000.

Is this a New Contract Request*

Yes

OneHealthPort ProviderSource Number

Not registered with ProviderSource or CAQH?

If you are not registered with ProviderSource or CAQH, please email your Washington Provider Application (WPA) or your Idaho Provider Application (IPA) to KPWA.provider-services@kp.org. Please include your Tax ID, Last Name, First Name and Credentials in the Subject Line.

INDIVIDUAL PRACTITIONER INFORMATION

Do you have multiple practitioners associated with this Tax ID?*

Yes

Please list Practitioner Names/NPIs

Practitioner FIRST Name*

Practitioner MIDDLE Name*

Practitioner LAST Name*

Practitioner Credentials*

Select

If this Practitioner is associated with any other Tax ID(s), please list them?

Sub-Specialty

Select

Do you offer Telehealth/Telemedicine Services?*

Yes

Which types of Telehealth/Telemedicine do you offer?*

Audio Only

Video Only

Both

Exclusively Telehealth/Telemedicine?*

Yes

Are you practicing from your home address?*

Yes

If you are practicing at your home address, do you want your home address viewable on the public provider directory?

If you select "No" you will not be listed on Kaiser's website.

Yes

As a matter of policy and as a part of our values, we keep records and perform certain analyses of our provider network pool by race, ethnicity and language. Your response will allow us to better meet member needs by allowing us to compare our provider network to the communities we serve.

Languages Spoken*

Select

Ethnicity-Do you consider yourself Hispanic/Latino?*

Yes, Hispanic or Latino: A person of Cuban, Mexican, Puerto Rican, South or Central American, or Spanish culture or origin, regardless of race.

Not Hispanic or Latino

Don't Know

Decline to answer

Race - Which category best describes your race?*

American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment.

Asian: a person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinents including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Island, Thailand and Vietnam.

Black or African American: A person having origins in any of the original peoples of Africa.

Native Hawaiian or other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific islands.

White or Caucasian: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa

Two or more races

Non-Specified

Does your organization collect demographic data for patients served?*

Data collected should include demographic information such as race, ethnicity, sex, gender identity, language, and disability status

Yes

How do you strive to provide culturally congruent care?

Definition of "culturally congruent care": Provide effective, equitable, understandable, respectful, and quality care and services that are responsive to diverse cultural health beliefs and practices, preferred languages, health literacy, and other communication needs.

Board Certification*

Date of Board Certification*

Practitioner's Email Address*

State License Number*

License Expiration Date*

License Issue State*

Select

Secondary License Number

Secondary License Issue Date

Secondary Issue State

Select

Secondary Expiration Date

Primary Practice Location NPI Number*

Primary Practice Location Taxonomy Code*

Individual NPI Number*

Individual Taxonomy Code*

You may find this information on https://nppes.cms.hhs.gov/webhelp/nppeshelp/TAXONOMY%20PAGE.html

Have you Opted out of Medicare?*

Yes

Enrolled in Medicare?*

Yes

CONTRACT INFORMATION

Contract Name on W9*

DBA:

Doing business as, if applicable

Contract Mailing Address*

Please enter street address, city, state and zip code. This address will be used for contract document & contract notification mail

Contract Contact Name*

Contract Contact Phone #*

Please enter just numbers, no dashes or Parentheses.

Contract Contact Email*

Contract Signatory Name*

Contract Signatory Title*

BILLING / REMIT TO INFORMATION

Billing / Pay to Name*

Billing / Pay To Street Address*

Billing / Pay To City*

Billing / Pay To State*

Select

Billing / Pay To Zip*

Billing Phone Number*

Please enter just numbers, no dashes or Parentheses

Billing NPI Number*

(Sole proprietors may use a type 1 NPI, PLC/LLC/Group entities please provide your registered type 2 NPI)

Billing Fax Number*

Please enter just numbers, no dashes or Parentheses

Billing Taxonomy Code*

CREDENTIALING INFORMATION

Credentialing Contact Name*

Credentialing Contact Phone Number*

Please enter just numbers, no dashes or Parentheses

Credentialing Contact Email*

PRACTICE DEMOGRAPHICS

Primary Practice Location Name*

The name of the Clinic this practitioner practices at primarily.

Primary Practice Location Street Address*

Primary Practice Location City*

Select or enter value

Primary Practice Location State*

Select

Primary Practice Location Zip*

Primary Practice County

Primary Practice Phone Number*

Please enter just numbers, no dashes or Parentheses

Primary Practice Fax Number*

Please enter just numbers, no dashes or Parentheses

Practitioners Practicing at New Care Site*

Is the Fax HIPAA Compliant?*

Yes

Clinic Operation Contact Name*

Clinic Operation Contact Email*

Use of Electronic Medical Record*

Yes

If Yes, Please provide name of EMR System*

EFT Enrolled*

Yes

Enrolled with OneHealthPort?*

Yes

E-Prescribing*

Yes

Wheelchair Access*

Yes

Secondary Practice Location Name

Secondary Practice Location Street Address

If this practitioner works at a second location, please note clinic name, etc. We only load up to 2 locations as a rule.

Secondary Practice Location City

Select or enter value

Secondary Practice Location State

Select

Secondary Practice Location Zip

Secondary Practice Phone Number

Please enter just numbers, no dashes or Parentheses

Secondary Practice Fax Number

Please enter just numbers, no dashes or Parentheses

Helpful Notes

Helpful notes regarding this submission

Additional Documents

Please upload your W9 and detailed letter of intent describing your request to contract. No action will be taken until all documents are received. (You may upload up to 10 documents.)

File Attachments

Drag and drop files here or

Date Submitted*

PLEASE VERIFY THE ACCURACY OF YOUR DATA PRIOR TO SUBMISSION. IF THE INFORMATION IS INACCURATE, WE CANNOT PROCESS THE REQUEST.

Send me a copy of my responses