Wayne Corporation

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Individual Provider Application

" Please complete the provider application below and click submit. Additional materials will need to be mailed to Wayne Corporation’s Home Office in order to complete the application process. If you wish to mail a hard copy of the application to Wayne Corporation, please download and print the .pdf version of the application ( download here ) and mail to the address at the top of the form along with all requested materials. "

Wayne Corporation, 1169 Eastern Parkway, Suite 1166, Louisville, KY 40217
Office: 502-451-8262 Fax: 502-456-6968 Website: www.waynecorp.com

INDIVIDUAL APPLICATION FOR APPROVED PROVIDER STATUS

Name:

Name of Practice:

Address:

City:

State:

Zip:

Telephone:

Fax:

Social Security #:

Federal Tax I.D.#:

Email Address:

If you have multiple office locations, please indicate other addresses and phone numbers:

Emergency contact phone number:

Mailing address (if different from primary address):

Names and credentials of those in group who would cover in your absence:

Day/Hours of Operation

Weekdays (Monday through Friday):

Weekend (Saturday and Sunday):

Operational Capabilities

Is your telephone answered 24 hours a day?

Yes No

Is your office accessible to the disabled?

Yes No

Is your office served by public transportation?

Yes No

What other cities/counties do you serve:

How many hours per week do you have that may be available for new referrals?

What is your usual waiting period for new clients?

Are you able and willing to make arrangements for emergency clients, e.g. need to be seen within 24 to 48 hours?

Yes No

Credentials

Professional degree:

Year Attained:

Training institution:

Licenses

State / Expiration Date:

Registration (if applicable)

Drug Enforcement Admin. Reg. No.:

Expiration Date

Controlled Dangerous Substances Reg. No.:

Expiration Date

Certification (if applicable)

Type:

Expiration Date

Type:

Expiration Date

Years In Practice:

Professional Liability Information

Current Carrier:

Address:

City:

State:

Zip:

Current Coverage Limits:

Aggregate: $

Occurrence: $

Date coverage first began

Expiration Date

History

Have any judgments ever been made against you in Professional Liability?

Yes No

Are there any claims or cases presently filed against you?

Yes No

Have you ever been censured by a professional board or association?

Yes No

Has any facility or organization dismissed you from its staff?

Yes No

Has any facility or organization revoked or suspended your general privileges?

Yes No

Has any facility or organization initiated either type of above actions by formal notice to you or your representative?

Yes No

Have you ever had criminal charges against you including illegal drug use?

Yes No

(Note: If you checked “yes” for any above item, attach a detailed description of the relevant facts, including the reason, the dates of action, and the final outcomes of these actions.)

Practice Information

Check client population you serve:

Senior Citizens
Family
Adolescents
Children
Adults
Groups
Couples

List any languages other than English that you speak:

Check the services you provide:

Evaluation and Referral

Mental Health
Substance Abuse

Specialized and Traditional Practice

Mental Health
Outpatient-General Practice
Outpatient-Specialized Practice
Substance Abuse

Brief Treatment

Mental Health
Substance Abuse

Crisis Evaluation/Intervention

Mental Health
Substance Abuse

Employee Assitance

Mental Health
Substance Abuse

Utilization Review

Inpatient
Outpatient

What physician services do you provide?

Inpatient:

Outpatient:

Medication evaluation
Medication review
Psychotherapy

List hospitals where you have admitting privileges:

RETURN THE FOLLOWING WITH THIS APPLICATION:

==> Copy of your current State License
==> Copy of your current Malpractice Insurance
==> Your Curriculum Vitae
==> Copy of any other applicable certification or registration
==> Board Certification (if applicable)

I hereby submit this application to be a provider in the Wayne Corporation network and understand that my application will be reviewed based on the information I have provided here. I understand that any misstatements in or omissions from this application could result in denial or subsequent termination of participation.

I also release from liability all individuals and organizations who provide information in good faith to Wayne Corporation concerning my qualifications as represented here.