Mental health practitioner provider certification application

Failure to complete and sign this certification may result in denial of future claim payment.

Request date: ______

Name: ______

Phone: ______National Provider Identifier (NPI) #: ______

Federal Tax ID #: ______□ EIN □ SSN Medicare #: ______

Office address: ______

City: ______State: ______ZIP: ______

Billing address (if different): ______

City: ______State: ______ZIP: ______

If joining a group practice, indicate name: ______

NPI# for group practice: ______Complete the special authorization form if the group will bill on your behalf.

Are you a hospital-employed physician? □ Yes □ No Location: ______

Are you employed by the U.S. Government? □ Yes □ No Location: ______

Enclose copy of licensure/certification. License #: ______□ Temporary/Limited □ Permanent

Issuing state: ______Date license was first issued: ______Expiration date: ______

Complete and sign the portion of this document that applies to your specialty.

I am applying for certification as a: □ Clinical □ Certified clinical social worker □ Clinical psychiatric nurse specialist □ Certified and therapist (will also need to fill out participation agreement) □ TRICARE certified counselor □ Pastoral counselor □ Supervised mental health counselor MENTAL HEALTH PRACTITIONER ATTESTATION EDUCATION/TRAINING/CLINICAL EXPERIENCE

By completing and signing the portion of this document that applies to your specialty, you attest that you meet the minimum qualifications as an authorized TRICARE provider as established by the 32 Code of Federal Regulations 199.6. You may be required to submit documentation in support of your attestation.

Clinical psychologist TRICARE certified mental health counselor

I certify that: I certify that I meet one of the following (please check the option • I am licensed or certified by the state for the independent which you have met and sign to attest that you meet the option that practice of psychology you have checked): • I meet one of the following (please check the option which you □ I am licensed for independent practice in mental health counseling have met and sign to attest that you meet the option that you by the jurisdiction where practicing. have checked) I have a Master’s Degree (or higher) in a mental health counseling □ I have a Doctorate degree in Psychology from a regionally program of education and training accredited for Mental Health accredited institution. I have two years of supervised clinical Counseling or Clinical Mental Health Counseling by the Council experience, at least one of which is post-doctoral, and at for Accreditation of Counseling and Related Educational Program least one of which is from an organized training program. (CACREP) accredited mental health counseling program. Name of institution/program: I have passed the National Clinical Mental Health Counselor Examination (NCMHCE), or the National Counselor Examination ______(NCE). I have a minimum of two years of post-master’s degree supervised City: ______State: ______mental health counseling practice that includes a minimum of 3,000 hours of supervised clinical practice and 100 hours of □ I am listed in the National Registry of Health Service face-to-face supervision. The supervision was provided by a Providers in psychology mental health counselor who is licensed for independent practice in mental health counseling in the jurisdiction where practicing Signature: ______and was conducted in a manner consistent with guidelines of the American Mental Counselors Association (A1\IHCA). Date: ______□ I am licensed for independent practice in mental health counseling by the jurisdiction where practicing. Clinical psychiatric nurse specialist I have a Master’s Degree (or higher) in a mental health counseling program of education and training accredited for Mental I certify that: Health Counseling or Clinical Mental Health Counseling from • I have a Master’s Degree in nursing with specialization in an educational institution accredited by a Regional Accrediting psychiatric and mental health nursing. Organization recognized by the Council for Higher Education • I meet one of the following (please check the option which you Accreditation (CHEA). have met and sign to attest that you meet the option that you I have passed the National Clinical Mental Health Counselor have checked) Examination (NCMHCE). □ I have two years post-masters degree practice in the field of I have a minimum of two years of post-master’s degree supervised psychiatric and mental health nursing with a minimum of 8 mental health counseling practice that includes a minimum of hours of direct patient contact per week. 3,000 hours of supervised clinical practice and 100 hours of face-to- face supervision. The supervision was provided by a mental health □ I am certified by the American Nurses Association through counselor who is licensed for independent practice in mental the American Nurses Credentialing Center. health counseling in the jurisdiction where practicing and was (Please return a copy of your certification with this packet.) conducted in a maimer consistent with guidelines of the American Mental Health Counselors Association (A1\.IHCA). Signature: ______Signature: ______Date: ______Date: ______MENTAL HEALTH PRACTITIONER ATTESTATION EDUCATION/TRAINING/CLINICAL EXPERIENCE

Supervised mental health counselor Certified marriage and family therapist

After December 31, 2014, this category or provider will no I certify that: longer be recognized by TRICARE and no reimbursement • I am licensed or certified as a marriage and family therapist; may be made to any person for services provided by this even if the jurisdiction in which I practice offers a license/ category of provider. For services rendered prior to January certification as optional or the jurisdiction where I practice 1, 2015 services may only be reimbursed when the following does not offer licensure or certification; therefore I am conditions have been met: TRICARE beneficiary is referred certified or eligible (submit documentation from the AAMFT for by a physician, a physician is providing ongoing of such eligibility) for full clinical membership in, the American oversight/supervision of the therapy being provided and Association for Marriage and Family Therapy (AAMFT). written communication of therapy results has or will be made • I also certify that I have a Master’s Degree from a regionally to the referring physician. accredited educational institution in an appropriate behavioral I certify that: science field, mental health discipline. • I meet one of the following (please check the option which you • I am licensed or certified for independent practice as a mental have met and sign to attest that you meet the option that you health counselor by the jurisdiction where practicing. have checked) • I have a Master’s Degree in mental health counseling or allied mental health field from a regionally accredited institution. □ 200 hours of approved supervision in the practice • I have two years of post-masters experience which includes of marriage and family counseling, completed in a 2 3,000 hours of clinical work and l00 hours of face-to-face to 3 year period, of which at least 100 hours were in supervision. individual supervision. Supervision occurred with more • I agree to the TRICARE reimbursement conditions than one supervisor and included a continuous process specified above. of supervision with at least three cases; 1,000 hours of clinical experience in the practice of marriage and family Signature: ______counseling under approved supervision, and involved at least 50 different cases.

Date: ______□ 150 hours of approved supervision in the practice of , completed in a 2 to 3 year period, of which at least 50 hours were under individual supervision; plus Certified clinical social worker 50 hours of approved individual supervision in the practice I certify that: of marriage and family counseling were completed within a period of not less than 1 nor more than 2 years; and 750 • I run licensed or certified as a clinical social worker by the hours of clinical experience in the practice of psychotherapy, jurisdiction where practicing or if the jurisdiction does not under supervision involving at least 30 cases and 250 hours provide for licensure or certification for clinical social workers, of clinical practice in marriage and family counseling under I am certified by a national professional organization offering approved supervision, involving at least 20 cases. certification of clinical social workers. • I also certify that I have a Master’s Degree in from I also agree to enter into a participation agreement with a graduate school of social work accredited by the Council of TRICARE (attach signed participation agreement) Social Work Education. • I have two years of 3,000 hours of post-master’s Signature: ______degree supervised clinical social work practice under the supervision of a master’s level social worker in an Date: ______appropriate clinical setting.

Signature: ______Note: Associate members or student members of the AAMFT are not eligible for consideration as authorized certified Date: ______marriage and family therapists. MENTAL HEALTH PRACTITIONER ATTESTATION EDUCATION/TRAINING/CLINICAL EXPERIENCE

Pastoral counselor Conflict of interest statement

I certify that: For TRICARE providers: • I am licensed or certified as a pastoral counselor; even if the Federal law (5 U.S.C. 5536) prohibits medical personnel, who are jurisdiction in which I practice offers a license/certification active duty members or civilian employees of the government, as optional or the jurisdiction where I practice does not offer compensation above their normal pay and allowances for licensure or certification; therefore I am a fellow or diplomat medical care rendered. This prohibition applies to TRICARE member in the American Association of Pastoral Counselors benefits whether the claim for reimbursement is filed by the (AAPC). individual who provided the care, the facility in which the care • I also certify that I have a Master’s Degree from a regionally was rendered, or by the sponsor/beneficiary. Claims for TRICARE accredited educational institution in an appropriate behavioral benefits will be denied in any situation where either a uniform science field, mental health discipline; and member or civilian employee of the uniform services has the • I meet one of the following (please check the option which you opportunity to exert, directly or indirectly, any influence on the have met and sign to attest that you meet the option that you referral of TRICARE beneficiaries to one or more providers on a have checked) selective basis.

□ A combination of 200 hours of approved supervision in the Please return to: practice of pastoral counseling, completed in a two to three year period, of which at least 100 hours were in individual WPS TRICARE Provider Certification supervision. Supervision occurred with more than one P.O. Box 7870 supervisor and included a continuous process of supervision Madison, WI 53707-7870 with at least three cases; 1,000 hours of clinical experience Please notify us of any changes related to your provider file in the practice of pastoral counseling under approved information (name, address, specialty, tax number, group supervision, and involved at least 50 different cases. affiliations, etc.) □ A combination of 150 hours of approved supervision in the practice of psychotherapy, completed in a two to three year period, of which at least 50 hours were under individual supervision; plus 50 hours of approved individual supervision in the practice of pastoral counseling were completed within a period of not less than one or more than two years; and 750 hours of clinical experience in the practice of psychotherapy, under supervision involving at least 30 cases and 250 hours of clinical practice in pastoral counseling under approved supervision, involving at last 20 cases.

Signature: ______

Date: ______

Note: A pastoral counselor may elect to be authorized as a certified marriage and family therapist due to the similarity of the requirements for licensure, certification, experience, and education, and as such, will be subject to all defined criteria for the certified marriage and family therapist category. However, no dual status will be recognized; pastoral counselors must elect to become one of the other. If a provider elects to use a facsimile signature (rubber stamp) or allow a representative to sign his/her name for certification of the services rendered, it is a TRICARE requirement that we have an authorization from the provider. Please complete the requested information on the authorization form below and return it to our office to assure prompt adjudication of your claims. Thank You.

Authorized signer

Hospital/Clinic name: ______IRS tax #: ______

Address: ______

City: ______State: ______ZIP: ______

Each of the below named representatives of this organization are hereby authorized to complete and sign all claim forms required by TRICARE and any related documentation that might be required by fiscal administrators of TRICARE on behalf of all physicians, dentists and other allied science professional staff members for authorized services, care and treatment rendered in the hospital or clinic to TRICARE patients.

The undersigned understands that this is continuing authorization and that the data on such claim forms is entered with the same authority, accuracy and effect as though executed by a member of the professional staff on whose behalf the form is completed. We understand that this authorization shall remain in effect until canceled or modified in writing by the undersigned or our successors in office.

The agents’ signatures and typed names and official titles with the organization as authorized above are as follows:

Name: ______Title: ______

Signature: ______

Signature of president: ______Date: ______(or other authorized officer of the governing body of the hospital, clinic or association)

Computer generated facsimile or rubber stamp authorization

Hospital/Clinic name: ______

National Provider Identifier (NPI) #: ______IRS tax #: ______

Address: ______

City: ______State: ______ZIP: ______

(Name) ______being first duly sworn, deposes and says: I hereby authorize Wisconsin Physicians Service Insurance Corporation to accept my facsimile or stamp signature, shown below, as my true signature for all purposes under the TRICARE program in the same manner as if it were my actual signature.

Signature: ______

Facsimile or stamp signature: ______

Subscribed and sworn to before me this ______(date) day of ______(month), 20______.

Notary public in and for ______county, state of ______, my commission expires ______(date).

Please mail or fax the completed form WPS TRICARE East Provider Certification Unit P.O. Box 7870 Madison, WI 53707-7870

Fax: 1-608-221-7535 SPECIAL AUTHORIZATION

I certify that I am an associate with the (name of clinic association):

______

Clinic address: ______

City: ______State: ______ZIP: ______

I also certify that I am not an intern or resident, and that I am licensed as indicated in this state (or, if licensing is not required, that I am eligible for membership in the national or state organization setting the standards for my allied science specialty).

I hereby authorize any of the duly authorized representatives of the above named organization as my agents to submit on my behalf claims for services provided TRICARE beneficiaries, and to receive on my behalf any payments which may be made pursuant to submission of such claims. It is understood and agreed that claims will be submitted only for services which are medically indicated for the proper care of the patient, and the services (where provided by other than a physician or dentist) were ordered by the attending physician or dentist and that the services were actually furnished.

I understand that I may withdraw this authorization at any time by giving written notice of such fact to the above named organization.

I also agree to hold the United States and its Fiscal Administrators under TRICARE harmless for any losses that might occur to me as the result of any action on the part of representatives of the above named organization after payment has been made by the United States or its Fiscal Administrators to said organizations for services which I have rendered, pursuant to a billing and claim submitted in my behalf in accordance with the terms of this agreement.

I also understand the making or conspiring to make a false, fictitious or fraudulent claim against the United States or one of its Fiscal Administrators renders such person liable to prosecution under applicable federal law.

Name: ______Title: ______

Specialty: ______SSN: ______

State license # if required or organization: ______

Signature: ______

Name: ______Title: ______

Specialty: ______SSN: ______

State license # if required or organization: ______

Signature: ______

Name: ______Title: ______

Specialty: ______SSN: ______

State license # if required or organization: ______

Signature: ______TRICARE PARTICIPATION AGREEMENT FOR CERTIFIED MARRIAGE AND FAMILY THERAPISTS

Name of certified marriage and family therapist: ______

Office address: ______

City: ______State: ______ZIP: ______

TRICARE provider billing number: ______Phone: ______

Article 1: Recitals Article 2: Performance provisions 1.1 Identification of parties 2.1 General agreement This participation agreement is between the United States The certified marriage and family therapist agrees to render of America through the Department of Defense, TRICARE, a medically necessary and appropriate covered mental health field activity of the Secretary of Defense, the administering services within the scope of his practice and licensure to activity for TRICARE and eligible TRICARE beneficiaries as required by this participation agreement and DOD 60101.8-R. The terms and conditions of ______DoD 6010.8-R are applicable to the participation or treatment of TRICARE beneficiaries by the certified marriage and family therapist are incorporated herein by reference. DBA ______(hereinafter designated certified marriage and family therapist). 2.2 Licensure and certification requirements The certified marriage and family therapist certifies and 1.2 Authority for certified marriage and family therapists as attaches hereto documentation that: authorized providers under TRICARE a. He/she is now licensed or certified to practice as a The TRICARE Department of Defense Regulation (DoD) marriage and family therapist by the state in which 6010.8-R, (32 Code of Federal Regulations Part 199), provides practicing or if practicing in a state which does not provide for cost sharing of services provided by certified marriage specific licensure or certification, the certified marriage and family therapists under certain conditions. and family therapist must be certified by or be eligible for full clinical membership in the American Association for Marriage and Family Therapy. 1.3 Purpose of participation agreement b. He/she has a recognized graduate professional education The purpose of this participation agreement is to: with a minimum of an earned master’s degree from a. Establish the undersigned certified marriage and family therapist an accredited educational institution in an appropriate as a TRICARE authorized provider of mental health services. behavioral science field, mental health discipline. b. Establish the terms and conditions that the undersigned c. He/she has the following experiences: certified marriage and family therapist must meet. 1. Either 200 hours of approved supervision in the practice of marriage and family counseling, ordinarily to be 1.4 Billing number completed in a two-to-three year period, of which at least 100 hours must be in individual supervision. This The certified marriage and family therapist’s billing number for supervision will occur preferably with more than one all mental health services rendered is the certified marriage supervisor and should include a continuous process of and family therapist’s social security number or employer’s supervision with at least three cases. identification number (EIN). This billing number must be used 2. 1,000 hours of clinical experience in the practice until the provider is officially notified by TRICARE of a change. of marriage and family counseling under approved The certified marriage and family therapist’s number is shown supervision, involving at least 50 different cases or on the face sheet of this agreement. It is the only billing number 150 hours of approved supervision in the practice of that will be accepted by TRICARE claims processors after the psychotherapy, ordinarily to be completed in a two-to- effective date of this agreement for becoming an authorized three year period, of which at least 50 hours must be certified marriage and family therapist under TRICARE. individual supervision; plus at least 50 hours of approved individual supervision in the practice of marriage and family counseling, ordinarily to be completed within a period of not less than 1 nor more than two years. TRICARE PARTICIPATION AGREEMENT FOR CERTIFIED MARRIAGE AND FAMILY THERAPISTS

c. 750 hours of clinical experience in the practice of 4.2 Termination of agreement by the office of TRICARE psychotherapy under approved supervision involving at The director, TRICARE or designee, may terminate this least 30 cases; plus at least 250 hours of clinical practice agreement upon written notice, for cause, if the certified in marriage and family counseling under approved marriage and family therapist is found not to be in compliance supervision, involving at least 20 cases. with the provisions set forth in DoD 6010.8-R, Chapter 6, or is determined to be subject to the administrative remedies 2.3 The certified marriage and family therapist agrees involving fraud, abuse, or conflict of interest as set forth in DoD 6010.8-R, Chapter 9. Such written notice of termination That having an exclusive election to participate in TRICARE as shall be an initial determination of purposes of the appeal certified marriage and family therapist, he or she will not be procedures set forth in DoD 6010.8-R, Chapter 10. authorized in any category of extramedical provider, either during or subsequent to the period this agreement is in effect. 4.3 Termination of agreement by the Certified Marriage and Family Therapist The certified marriage and family therapist may terminate Article 3: Payment provisions this agreement by giving the Director, TRICARE, or designee, written notice of such intent to terminate at least 60 days in 3.1 TRICARE determined allowable charge advance of the effective date of termination. Effective the date The TRICARE determined allowable charge is the maximum of termination, the certified marriage and family therapist amount that TRICARE will authorize for services rendered by will no longer be recognized as an authorized provider under a TRICARE authorized individual professional provider of care. TRICARE, and reinstatement shall be disallowed for any other The TRICARE determined allowable charge is determined category of extramedical individual provider under TRICARE. following the provisions set forth in DoD 6010.8-R, Chapter 14. Subsequent to termination the certified marriage and family therapist may only be reinstated as an authorized TRICARE 3.2 TRICARE determined allowable charge as payment in full extramedical provider by entering into a new participation The certified marriage and family therapist agrees to accept agreement as a certified marriage and family therapist. the TRICARE determined allowable charge as payment in full for services rendered to TRICARE beneficiaries, except for 4.4 Amendment by the office of TRICARE applicable deductible and cost shares. a. The director, TRICARE, or designee, may amend the terms of this participation agreement by giving 120 days notice 3.3 Hold harmless in writing of the proposed amendment(s) except when The certified marriage and family therapist agrees to hold necessary to amend this agreement from time to time to eligible TRICARE beneficiaries harmless for non-covered care incorporate changes to TRICARE regulations. When changes (i.e., certified marriage and family therapist may not bill a or modifications to this agreement result from changes to beneficiary for non-covered care and may not balance bill the TRICARE regulations through rule making procedures, the beneficiary for any amount above the TRICARE determined Director, TRICARE, or designee, is not required to give 120 allowable charge). days written notice. Any such changes to DoD 6010.8-R shall automatically be incorporated herein on the date the regulation amendment is effective. b. The certified marriage and family therapist, not wishing Article 4: Term, termination and amendment to accept the proposed amendment(s), including any amendment resulting from changes to the TRICARE 4.1 Term regulations accomplished through rule making The term of this agreement shall begin on the date this procedures, may terminate participation as provided agreement is signed and shall continue in effect until for in this article. However, if the certified marriage and terminated by either party. family therapist notice of intent to terminate participation is not given at least 60 days prior to the effective date of the proposed amendment(s), then the proposed amendment(s) shall be incorporated into the agreement for services furnished by the certified marriage and family therapist between the effective date of the amendment(s) and the effective date of termination of this agreement. TRICARE PARTICIPATION AGREEMENT FOR CERTIFIED MARRIAGE AND FAMILY THERAPISTS

Article 5: Effective date Please mail or fax the completed form 5.1 Date signed Mail: This participation agreement is effective on the date signed WPS TRICARE East Provider Certification Unit by the director, TRICARE or designee. P.O. Box 7870 Madison, WI 53707-7870 TRICARE

Name: ______Fax: 1-608-221-7535 Title: ______

Signature: ______

Certified marriage and family therapist

Name: ______

Title: ______

Signature: ______

Executed on ______, 20_____ .