Practitioner Application

This application is for new individual practitioners not currently participating in the CDPHP® network. Individual practitioners who are already credentialed/participating with CDPHP and are requesting an address/tax ID change or other demographic update should complete the Practitioner Information Change Request Form.

To contract with CDPHP as a facility or ancillary provider offering laboratory, durable medical equipment (DME), home health care, home infusion, transportation, imaging, dialysis, hospice, or skilled nursing services, please contact Healthcare Network Strategy at (518) 641-4290 or HNS_Recruitment@cdphp.com.

If you have any other questions while completing this application, please contact the CDPHP Credentialing Department at (518) 641-3321 or CDPHP_Cred_Dept@cdphp.com for assistance.

IMPORTANT: The New York State Department of Health requires practitioners – with a few exceptions* – to have a NY Medicaid Management Information System (MMIS) ID number prior to enrollment with CDPHP Medicaid, HARP, or Child Health Plus (CHP).

To apply for a NY MMIS ID, visit https://www.emedny.org/info/ProviderEnrollment/index.aspx.
For questions regarding MMIS, contact Provider Services at (518) 641-3500.

*Exceptions include: Acupuncturist (LAc) and Orthoptist (CO).

Mid-Level Provider:*

Supervising or Collaborative Physician Name:*

Supervising or Collaborative Physician NPI:*

Associated with an IPA:

Does the provider currently have a New York MMIS number?:*

Please enter the New York MMIS Number:*

Has the provider applied for a New York MMIS number and the application is pending?:*

Applying as an Individual or with a Group Practice?*

Employer Tax Identification Number (TIN):*

Practitioner Direct Email Address:*

Confirm Email Address:*

Practitioner Primary Service Address:*

Confirm Email Address:*

Practicing as part of SW Vermont Medical Center

Credentialing Street Address:

Has the practitioner opted out of CMS-Medicare?*

Is the practitioner an HIV-experienced provider?*

Is the practitioner a certified lactation consultant as certified by the International Board of Lactation Consultant Examiners?*

Does the practitioner provide outpatient medication-assisted treatment (MAT)?*

Does the practitioner prescribe Buprenorphine?*

Yes No

Does the practitioner prescribe Buprenorphine at all servicing locations?*

Yes No

Please list the group and service addresses of the locations the practitioner prescribes Buprenorphine at

Does the practitioner prescribe Vivitrol?*

Yes No

Does the practitioner prescribe Vivitrol at all servicing locations?*

Yes No

Please list the group and service addresses of the locations the practitioner prescribes Vivitrol at

Is the practitioner a behavioral health provider?*

If the practitioner is affiliated with an Office of Mental Health (OMH) or Office of Addiction Services and Supports (OASAS) licensed outpatient facility(ies), please list the facility(ies) here:

Does the practitioner currently offer services via telemedicine to patients?*

Yes No

Please select one of the following:*

Treats Children (Under 18) Treats Adults (18+) Treats All Ages

Please select up to eight areas in which practitioner have a specific focus, specialty, or expertise:*

- The practitioner/practice will not seek reimbursement from member for conversion therapy services

- The practice has a process in place to review managing employees and agents against federal exclusion lists

Abuse, Assault, and Trauma	End of Live Issues
Adoption	Eye Movement Desensitization Reprocessing (EMDR)
Anxiety and Panic Disorders	Family Therapy
Attention Deficit Hyperactivity Disorder	Gay/Lesbian/Bisexual Issues
Autism Spectrum Disorders	Gender Identification/Transgender Issues
Bariatric Assessment	Geriatrics
Behavior Modification	Grief/Bereavement
Bipolar Disorders	Group Therapy
Chemical Dependency/Drug Addiction	HIV/AIDS Related Issues
Christian Counseling	Infertility
Cognitive Behavioral Therapy (CBT)	Men’s Issues
Compulsive Gambling	Obsessive Compulsive Disorders
Cultural/Ethnic Issues	Pain Management
Depression	Personality Disorders
Dialectical Behavioral Therapy (DBT)	Postpartum Issues
Dissociative Disorders	Schizophrenia/Psychotic Disorders
Divorce/Blended Family Issues	Sexual Disorders
Eating Disorders	Women’s Issues
Electroconvulsive Therapy (ECT)	No specific area of focus or specialty

Practitioner Application

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Practitioner Primary Service Address

Credentialing Contact

Affiliated with (Check any that apply):

Credentialing Mailing Address (if different than above)