Get Affiliate Application - Empathia

This guide provides clear and step-by-step instructions on filling out the Affiliate Application - Empathia online. By following these instructions, users can ensure their application is complete and submitted correctly.

Follow the steps to successfully complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred editor.
2. Begin with the provider information section. Fill in your first name, middle name, last name, social security number, date of birth, national provider ID, clinical experience in years, and gender. If a section is not applicable, indicate it clearly with N/A.
3. Move on to the licensure section. Indicate all licenses and certifications you possess in relevant states. Include your current license class, license number, issue date, state, and expiration date.
4. Complete the certifications section by listing any alcohol and drug certifications, including the relevant details like licensure number and expiration date. Don’t forget to attach copies of certifications.
5. Fill in office information, including your practice type and primary contact information. Make sure to also provide your Tax Identification Number or Social Security Number for billing purposes.
6. In the education and training section, indicate your highest degree attained along with the year it was awarded and the name of the institution.
7. Proceed to the practice overview section to describe your practice in 50 words or less. Answer questions regarding your availability and consultation record-keeping.
8. Continue to the professional memberships section by listing all organizations you are a member of, ensuring to attach proof of your memberships.
9. Document your experience with insurance plans that you accept by checking the relevant boxes.
10. Complete the EAP experience section, providing details about your EAP memberships, years of experience, and the types of services you offer.
11. Answer the disclosure questions truthfully. If you answer 'yes' to any questions, be prepared to provide the required detailed explanations.
12. At the end of the application, review all sections for accuracy. Once completed, save your changes and you can choose to download, print, or share the form as necessary.

Ensure you complete your application accurately and submit it online to join the Empathia network.