Download Affiliate Provider Application

AFFILIATE PROVIDER APPLICATION QUICK CHECK

Please be sure to include all of the information indicated on this checklist.

  Photocopy of state license and certificates with an expiration date that is clearly visible on the copy.
     State License
     Critical Incident Certificate (ICISF, Red Cross)
     CAC (Certified Addiction Counselor)
     SAP (Substance Abuse Professional)
     DOT SAP (DOT Substance Abuse Professional)
     Criminal Clearance Certificates (State & FBI)
     Child Abuse Clearance Certificate

  Photocopy of face sheet of insurance policy which exhibits proof of professional liability coverage, indicating limits of coverage and expiration date (provider must be named as the insured)
  Curriculum Vitae (resume) which includes dates and locations of education and post-graduate training.  PLEASE DESCRIBE IN DETAIL the populations, problems and disorders treated as well as the theoretical orientation of your work.
  A list of Continued Education Programs or workshops attended over the last 24 months and credits received, including annual professional society certification when possible.  (This is required even if your state does not require continuing education to maintain state licensure).
  Information pertaining to closed and/or active malpractice suits and/or ethics board complaints within the past 5 years.  Primary verification releases should be mailed to your licensing and malpractice insurance boards.
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PLEASE NOTE:  Incomplete and unsigned applications delay the credentialing process.  If any information on your application is incomplete, your application will be returned to you.  LMA will only review each provider's application a maximum of two times.

Using this QUICK CHECK will help to ensure that your application is complete.

Return completed application and supporting documents to:

LIFE MANAGEMENT ASSOCIATES
1848 Charter Lane
Lancaster, PA  17601-5896
Phone:  717-394-6688 / 800-327-7770
Fax:  717-509-8879