CareFirst Anthem PPO ☐ ☐ Medicaid Anthem Health Keepers ☐ ☐ Kaiser Mid Atlantic Anthem Health Keepers + ☐ ☐ Aetna Optima ☐ ☐ Cigna BCBS ☐ ☐ Anthem Medicaid United Behavioral Health ☐ ☐ Insurance Panels United Healthcare ☐ None ☐ Accepted: Tricare ☐ ☐ Other (please list): (Please check all Humana ☐ that apply) INTotal Health ☐ Anthem ☐ Anthem HMO ☐ Proposed Hourly Rate $ __________________ (Propose an hourly rate which takes into consideration the nature of this partnership.): After hours and emergency protocols: (Please describe) STBH PROVIDER APPLICATION PART 1 CHECKLIST (Please check off and be sure to attach all required documentation outlined below.) Insurance Accord Certificate for the Provider ☐ W-9 form for the Provider (tax identification) ☐ Part 2: STBH Clinician Authorization Form(s) - one form MUST be completed for each clinician ☐ All the information in this application is accurate and truthful. This application is submitted with the intent to enter an Agreement for the Purchase of Services. _______________________________________ ______________________ Signature of Authorized Representative/Title Date ______________________________________________ Print Name 2 | P a g e
Insurance Panels Accepted: (Please check all that apply) ☐ CareFirst ☐ Medicaid ☐ Kaiser Mid Atlantic ☐ Aetna ☐ Cigna ☐ Anthem Medicaid ☐ United Healthcare ☐ Tricare ☐ Humana ☐ INTotal Health ☐ Anthem ☐ Anthem HMO ☐ Anthem PPO ☐ Anthem Health Keepers ☐ Anthem Health Keepers + ☐ Optima ☐ BCBS ☐ United Behavioral Health ☐ None ☐ Other (please list): Proposed Hourly Rate (Propose an hourly rate which takes into consideration the nature of this partnership.): $ __________________ After hours and emergency protocols: (Please describe) STBH PROVIDER APPLICATION PART 1 CHECKLIST (Please check off and be sure to attach all required documentation outlined below.) ☐ Insurance Accord Certificate for the Provider ☐ W-9 form for the Provider (tax identification) ☐ Part 2: STBH Clinician Authorization Form(s) - one form MUST be completed for each clinician All the information in this application is accurate and truthful. This application is submitted with the intent to enter an Agreement for the Purchase of Services. _______________________________________ ______________________ Signature of Authorized Representative/Title Date ______________________________________________ Print Name 2 | P a g e