Licensing Section

Enter licensing information for a contracting provider.

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1. In the State Dept. of Health Services License Expiration Date field, enter the license expiration date.

2. In the State Dept. of Health Services License Number field, enter the license number.

3. In the CARF Expiration Date field, enter the CARF license expiration date.

4. In the State MH Provider Number Expiration Date field, enter the State MH provider number expiration date.

5. In the Copy of Medicaid Application on File field, select Yes if the application is on file.

6. In the Employ. Contract for Any Health Care Org. Ever Terminated field, select Yes if employment was terminated in the past.

7. In the Ever Had a Problem With DEA/Other Narcotic Registration field, select Yes if the provider has had a problem.

8. In the Ever Had a Medicaid or Medicare Program Participation Problems field, select Yes if the provider has had a problem.

9. In the 'Explanation' fields, enter the explanation for the associated problem.

10. In the Filed a Professional Liab. Claim in Past 3 Years field, select Yes if a liability claim was filed.

11. In the Have You Ever Had a Malpractice Settlement field, select Yes if a malpractice settlement was filed.

12. In the Have You Ever Had Your State License Revoked, Suspended, Etc. field, select Yes if this is true.

13. In the Is Explanation Attached field, select Yes if the explanation is attached.

14. In the Licensing State Agency field, select the state agency.

15. In the State Program License field, enter the license.

16. In the Rec'd Copies of Curr, Malpractice Insurance Declaration field, select Yes if copies were received.

17. In the Received Copies of Current DEA License (Psychiatrists Only) field, select Yes if copies were received.

18. In the Received Copies of Current State License/Certification field, select the state license.

19. In the State Dept. of MH Medicaid Provider Number field, enter the number.

20. In the State License Number field, enter the number.

21. In the State License Expiration Date field, enter the expiration date for the CARF license.

22. In the Type of License field, select the license type.