Behavioral Health contract request

Please provide your facility or provider name, including DBA (as it appears on W-9).
Some answers you provide may require additional documentation. Please have your documentation ready to attach, such as Rule 29, CTSS, Rule 25 assessment, etc.
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Provider information

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Contact information

Please include the services offered, the number of clinic locations and practitioners and their practicing specialties. Indicate any cultural or ethnic proficiencies or accreditations/certifications held (i.e. AAAHC, ACHC, CARF, CCAC, CHA, HFAP, JCAHO, Essential Community Provider (ECP), Federally Qualified Health Center (FQHC), Indian Health Service (IHS) or Rural Health Center (RHC)).
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