EAP Affiliate Provider Application

General Information:
First Name:
Last Name:
Practice Name:
Phone:
Emergency Phone:
Office Address:
Office City:
Office State:
Office Zip:
Home Office:Yes No
Email Address:


Education:
Highest Degree:
University:
Program:
Year Graduated:


Certification/Licensure:
Mental Health Certification/Licensure:
State:
Type of Certification/Licensure:
Certification/License Number:
Year Attained:

Alcohol/Drug Certification:
State:
Type of Certification/Licensure:
Certification/License Number:
Year Attained:

CEAP Certification:
State:
Type of Certification/Licensure:
Certification/License Number:
Year Attained:


*I have professional liability insurance in the amount of $1 million or more per occurrence:YesNo


Office Hours:
Monday:amtopm
Tuesday:amtopm
Wednesday:amtopm
Thursday:amtopm
Friday:amtopm
Saturday:amtopm
Sunday:amtopm


Facilities
My office provides the following:
Parking:YesNo
Handicap accessibility:YesNo
Pet-free environment:YesNo
Smoke-free environment:YesNo
Private waiting room:YesNo
Bilingual Services:YesNo
Languages:


Services and Populations
Please indicate areas that you are qualified to assess, counsel or refer:
Specialized populations Assess Counsel Refer None
Children (<6):
Children (6-12):
Adolescents:
Adults:
Geriatrics:
Gay/Lesbian:
Men's Issues:
Women's Issues:
Veterans:
Specialty Areas
ADHD:
Anger Management:
Anxiety Disorders:
Bipolar Disorder:
Career Counseling:
Chemical Dependency:
Chronic Pain:
Depression:
Developmental Disorder:
Eating Disorder:
Employer Mandated:
Fit for Duty:
Gambling:
Grief/Loss:
Impulse Control:
Learning Disorder:
Marital/Family:
Multiple Personality:
Parenting Issues:
Perpetrators:
Personality Disorders:
Phobias:
Psychosis:
PTSD:
Sexual Dysfunction:
Sleep Disorders:
Smoking Cessation:
Somatic:
Spiritual:
Stress Management:
Victim Issues:
Workplace Violence:


For Quality Assurance purposes, MUSC Health EAP requires your response to the following questions.
If you answer 'Yes' to any of these questions, please include a written explanation of the circumstances
surrounding each item in the space below.

YesNo
Has your professional license / certification ever been denied, revoked, suspended, or limited?
Is there any action pending to revoke, suspend, or limit your professional license / certification?
Have you ever been denied professional liability insurance, or has your insurance ever been canceled or denied renewal?
Have any certifications, such as the Certified Employee Assistance Professional (CEAP) certification, ever been revoked, suspended, or limited?
Do you have any ongoing physical or mental impairment or condition which would make you unable, with or without reasonable accommodation, to perform the essential functions of a practitioner in your area of practice, or unable to perform those functions without a direct threat to the health and safety of others?
Is there any legal action pending related to your practice?
Have you ever been the subject of disciplinary proceedings by any professional association or organization (i.e., state licensing board; county, state, or national professional society; hospital, medical, or clinical staff)?
Do you currently use illegal drug or abuse drugs or alcohol?
Do you have a history of chemical dependency or substance abuse that might adversely affect your ability to competently and safely perform the essential function of a practitioner in your area of practice?
Have you ever been convicted of a felony or involved in charges relating to moral or ethical turpitude?
Have you ever been named as a defendant in a criminal proceeding?
Have you had any malpractice claims during the past 5 years?
Have you ever been a defendant in any lawsuit involving your practice where there has been an award or payment of $25,000 or more?

Explanation Space:


Professional References:
Name:Title:Phone#:


By clicking 'Submit Application' below, I, the undersigned, hereby attest that all the information enclosed is complete and accurate and fairly represents my clinical qualifications. Further, I attest that all the enclosed is truthful information. I authorize MUSC EAP to consult with or request from any third party who may have information bearing on any subject addressed by this application and inspect or obtain records or documents is said third parities that may be relevant to this application. I also authorize any third parties to release information to MUSC EAP and any authorized representative upon request. I hereby release MUSC EAP and any representatives from any liability for any such reports or documents, which holds information pertinent to this application.

I hereby authorize and request any educational institution or programs, professional review organizations, employers, peer review bodies, insurance carriers, or others to disclose to MUSC EAP upon request information and documentation as will reasonably assist MUSC EAP in its efforts to determine my professional and personal qualifications for the affiliate position for which I am applying.



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