PVP - ACMS Mental Health Provider Contract Application

ACMS PVP Mental Health Provider Application

This is a multi-phase form. For initial inquiries, you will only need to fill out limited information for ACMS to decide if you meet the minimum qualifications for contracted mental health providers (MHPs). Once you put your name and email address into those fields, you may save progress on this form at any time, with a button at the bottom of the form.
Minimal Licensure*

Idaho Licensed Clinical Social Worker (LCSW)Idaho Licensed Clinical Professional Counselor (LCPC)Idaho Licensed Marriage Family Therapist (LMFT)Idaho Licensed Psychologist (Psy-D/PhD)Psychiatrist (Psychotherapy Only)Other
At this time, our program only allows for Idaho Licensed LCSWs, LCPCs, LMFTs, Psychologists, and Psychiatrists. We will not be able to consider your inclusion in the program as a contracted provider unless you are licensed within one of the categories above.
MHP Name*

First NameLast Name
Your Email (not public)*
example@example.com
Personal Contact Number (not public)*

Area CodePhone Number

MHP General Information
The nature of our program is that many physicians or other clinicians need urgent and timely access to mental health because of their peculiar work hours and blocks. To this end, accessibility and availability of appointments under certain circumstances might want to be made within 24-48 hours.
Does your appointment calendar currently allow for urgent or timely requests for appointments made by our members within that time frame?*

YesPerhaps-I would need to know moreNo
At this time, we are looking for MHPs who have availability that meets the need of our particular member population. When your calendar opens up for more urgently made appointments, please check back with us.
Days and Hours of General Availability*
Please describe your experience working with medical professionals and understanding of the occupational challenges they face and what drives them.*
Preferred Appointment Method*

In-PersonTelehealthEither
Practice Name (if different than first and last or if incorporated or LLC)
Address of Clinic

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Education and Qualifications
Masters Degree/University/Year Graduated*
Doctoral Degree/University/Year Graduated
List any other CURRENT certifications you hold (EMDR, EFT, etc.)*
Specific treatment foci or modalities*
see https://www.physicianvitality.org/pvp-therapists for existing listing samples
Do you have any POTENTIAL conflict of interest in terms of serving ACMS member physicians, nurse practitioners, physician assistants, etc. Examples might include: Serving on a board/committee that regulates or investigates potential ACMS member clients or as part of your practice, having a close family relative who is a licensed medical professional and potentially/actually an ACMS member, etc. This is not a disqualification, but should be disclosed for explanation.
Can you provide a physician of reference for us that you know professionally or personally (who is not a client). Describe your relationship to them and their contact information (phone/email) where we could reach them.

ACMS PVP Mental Health Provider Application