NETWORK DEVELOPMENT - s21151.pcdn.co

Please complete form and email to: BEACON HEALTH STRATEGIES. NETWORK DEVELOPMENT . Letter of Interest form *MUST SUBMIT W-9 FOR CONSIDERATION. Provider Name/Legal Entity Name (W-9). Requesting Individual (if different). Date Licensure(s) (LICSW, MD, LMHC). Tax Identification Number (TIN). NPI. Practice Address Mailing Address Phone Number Email Fax Number Medicare Number Medicaid Number Languages Availability Years of Experience in Private Practice Description of Services: please be specific and list specialties inpatient services, outpatient services, diversionary services, home based services, autism services and others: Service Availability and Hours of Operation Required: Provider shall maintain a system of 24-hour on-call services. Crisis intervention services must be available 24 hours per day, 7 days per week. After hours, providers should have a live telephone answering service or an answering machine that specifically directs a member in crisis to a covering physician, agency-affiliated staff, crisis team or hospital emergency room.

Form . W-9 (Rev. December 2014) Department of the Treasury Internal Revenue Service . Request for Taxpayer Identification Number and Certification

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