Therapist Enrollment

This form is for therapists to enroll in different insurances as an individual or as a member of a group.

Name(Required)

First Last

Phone(Required)

Email(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth(Required)

SSN(Required)

Degree(Required)

Type of License(Required)

State License #(Required)

CAQH #(Required)

Date of Issue(Required)

Expiration Date(Required)

NPI #(Required)

Primary Specialty(Required)

CAQH Username(Required)

CAQH Password(Required)

Client Preferences(Required)

Individual

Couples

Children

Teenagers

Men

Women

LGBT

Copy of Professional License(Required)

Max. file size: 256 MB.

Copy of Driver's License(Required)

Max. file size: 256 MB.

W-9 for Primary Practice

Max. file size: 256 MB.

Copy of Liability Insurance(Required)

Max. file size: 256 MB.

Consent(Required)

I agree to Restoring Hopes using this submitted information to enroll me onto different insurance panels.

Comments

This field is for validation purposes and should be left unchanged.