Private Practice Garden LLC

Please follow instructions in the email entitled "Next Steps"

First Name

Middle Name

Last Name

Maiden Name (if applicable)

SSN

DOB

Gender Identication

Race

Languages Spoken

Sexual Orientation (Voluntary Response

Religion (Voluntary Response)

Military Status (Branch/Active or Reserves)

Board Certification (Type/Org/Number/Dates)

Professional Licensure (State/Number/Initial & Exp Date)

Additional Professional Licensure (State/Number/Initial & Exp Date)

DEA (if applicable)

State Pharm #(if applicable)

Supervising MD-Name/State (For NP/APRN only)

Clinical Supervisor-Name/State/Licensure/Licensure# (for provisionally licensed MH provider)

Check All that Apply (if any apply, please send detail explanation)

License or Certification Revoked

Unable to Bill Medicare & Medicaid

Criminal Charges (Jailed/Arrested/Adjuncated)

Practice Name

Practice Website

EIN

Ind NPI

Group NPI

Service Address

Billing Address

Practice Days and Hours

Check that apply

Service Location is Handicap Accessible?

Service Location near Public Transport?

Office Phone #

Fax Phone #

Appt Phone #

Provider Email

Office Email

Billing Email

Malpractice Provider (Name/Policy#/Start Date/Exp Date)

Languages Spoken by Office Staff

EHR Used/URL of Electronic Health Record

Billing Service for Group (Name/Contact Email)

Who will sign contracts? (Name/Email)-if its you as provider mark Self

Telehealth Only, Hybrid and/or Going into Pt's Home

Professional School (Name/Address/Ph#/Degree/Dates)

Undergrad School (Name/Address/Ph#/Degree/Dates)

References (Name/Licensure/Email)

Preferred Client (Check all that apply)

Children

Adult

Geriatric

Families

Couples

Groups

Infants

Conditions to Treat

Anxiety

Depression

ADHD

Substance Abuse

Trauma

Grief

Other Conditions You Treat

Preferred Treatment Modalities

Additional Certifications

Indicate line of business you want for your contract

Commercial

Medicare

EAP

Medicaid

Marketplace

CAQH (No/User ID/Password)

NPI Website Login (User ID/Password)

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