Get Substance Use Disorder Credentialing

This guide provides essential information on how to fill out the Substance Use Disorder Credentialing form online, ensuring a smooth application process. Follow the steps below to complete the form accurately and efficiently.

Follow the steps to complete your credentialing form online.

1. Click ‘Get Form’ button to obtain the Substance Use Disorder Credentialing form and open it for editing.
2. In the applicant section, fill in your last name, first name, and middle name. Provide your birth date in the format mm/dd/yyyy.
3. Complete your address details including city, state, and zip code. Enter your phone number, ensuring it is a 10-digit number. Include your business phone number as well.
4. In the direct supervisor section, input the supervisor's last name, first name, and middle name. Include their credential number, street address, city, state, and zip code. Also, specify their phone number as a 10-digit number.
5. Document the dates of supervised experience by indicating the start date (mm/dd/yyyy) and end date (mm/dd/yyyy).
6. Under competencies gained during supervised experience, confirm the observation of the first fifty hours of face-to-face client contact by selecting the appropriate option.
7. Have the supervisor sign and date the form, certifying the accuracy of the information provided.
8. Fill in the required hours for face-to-face clinical evaluation, other clinical evaluation, and face-to-face counseling, based on the hours required in each category.
9. In the statement of qualifications section, the supervisor must detail their qualifications and attest to meeting the certification requirements.
10. After completing the form, review all entries for accuracy. Save the changes, and choose to download, print, or share the form as needed.

Complete your Substance Use Disorder Credentialing form online today to ensure timely processing of your application.