Provider Request to Join Network – Allied Trades Online

How would you like your facility/provider name and address to appear in our system?(Required)

Servicing Address(Required)

Street Address Address Line 2 City State ZIP Code

What is your billing address (if different from above)?

Street Address Address Line 2 City State ZIP Code

What is the best phone number for ATAP to give to members when they are seeking a referral?(Required)

What is the best fax number for your office?

What is the best email address for your office?(Required)

Tax ID#(Required)

Which of the following types of services does your provider/facility offer? Please check all that apply.(Required)

Inpatient mental health services

Partial hospitalization mental health services

Intensive outpatient mental health services

Outpatient mental health services

Inpatient substance use disorder services

Partial hospitalization substance use disorder services

Intensive outpatient substance use disorder services

Outpatient substance use disorder services

Which of the following applies to your practice? Please check all that apply.(Required)

No Telehealth Services

Offering Telehealth Services

Solely a Telehealth Practice

Which of the following specialties does your provider/facility offer? Please check all that apply.(Required)

Please Specify

What types of clients does your provider/facility serve? Please check all that apply.(Required)

Children under age 5

Children aged 5-10

Children aged 10-14

Adolescents aged 14-18

Adults aged 18+

Older adults 50+

Males only

Females only

Does your provider/facility have a child therapist on staff?(Required)

Yes

Is your provider/facility currently accepting new clients?(Required)

Yes

Does your provider/facility have a child psychiatrist on staff?(Required)

Yes

Languages spoken other than English?

Is your provider/facility in network with the following Insurances?(Required)

If there is any other information that you think is important for ATAP to have, please describe below.

Upload a copy of your liability insurance in PDF or MS Word format.

Max. file size: 2 MB.

Upload a copy of your State License in PDF or MS Word format.

Max. file size: 2 MB.

Upload a copy of your W9 in PDF or MS Word format.

Max. file size: 2 MB.

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