Behavioral Health, Psychiatry, Psychology, ABA & Substance Use Providers - Client Discovery Form

Credentialing Client Discovery Form

Behavioral Health, Psychiatry, Psychology, ABA & Substance Use Providers

Purpose: This form collects provider, practice, services, location, documentation, payer, supervision, compliance, and enrollment details needed to assess Medicare/Medicare Advantage, Medicaid, Medicaid MCO, Commercial plans where applicable, and provider enrollment requirements for behavioral health, psychiatry, psychology, ABA, SUD, and related mental health provider types.

Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Instructions: Complete every applicable field. Select only services currently provided or planned. Items marked “if applicable” may not apply to every provider, program, or organization type. Upload protected or sensitive documents only through the secure upload process.

Draft ready
0% complete

1. Primary Client Contact & Organization Information

Must match signed service agreement.

Primary Service Location *

Secondary Contact, if available

Organization Type

2a. Key Identifiers

Exactly 9 digits.
State(s) of Licensure *

2b. Ownership, Management & Administrative Structure

3. Scope of Work

Services Purchased / Requested *
Target Payer Categories *
State(s) for Enrollment *

4. Key Project Information

5. Provider Type / Credentials

6. Mental Health & Behavioral Health Services Offered

A. Psychiatry / Medication Services

B. Psychology / Testing / Assessment Services

C. Therapy / Counseling Services

D. ABA / Autism Services

E. Substance Use / Addiction Services

F. Peer Support / Case Management / Community-Based Services

7. Patient Populations Served

8. Locations & Service Delivery Information

States Where Telehealth Is Provided

Locations & Hours of Operation

Common Place of Service Codes Used

9. Provider Billing & Coding Information

10. Provider Enrollment Roster

Complete one row per provider, clinician, supervised/associate-level clinician, ABA provider, peer support specialist, case manager, or related staff member requiring payer enrollment, credentialing, roster addition, supervision review, or billing setup.

Provider NameType / RoleIndividual NPILicense / Certification State # / Exp.CAQH IDEnrollment ScopeSupervision Required?Action

11. Payer Network & Contracting Goals

12. Supervision, Collaborative Providers & Staff

Supervision / Staffing Notes

13. Facility, Program, Licensure & Accreditation Considerations

14. Compliance Protocols

15. Additional Notes / Special Considerations

16. Upload Supporting Documents

Upload protected, personal, or sensitive information only through the approved secure upload process. Do not email these documents.

Provider-Level Documents

Organization / Practice Documents

17. Client Acknowledgements, Signatures & Certification

Please review the following requirements carefully before submitting this discovery form.

Privacy, Confidentiality, and Security of Credentialing Documents

To maintain compliance with HIPAA and to safeguard Client privacy, confidentiality, and data security, credentialing documents containing protected, personal, or sensitive information should be uploaded only through TriumpHealth’s approved secure process and should not be sent through unsecured email, fax, or postal mail unless specifically instructed.

CAQH / PECOS / NPPES / Payer Portal Access

If the Client cannot provide required profile, portal, or payer access, credentialing applications, attestations, revalidations, EFT/ERA/EDI setup, or roster updates may be delayed or denied.

Primary Location Address

I verify that the primary location address provided above is not a virtual office, mail drop, P.O. Box, mailbox service, or other address that fails to meet payer enrollment requirements unless specifically permitted by the payer.

I certify that the information provided in this form is true, complete, and accurate to the best of my knowledge. I authorize use of this information for payer enrollment, credentialing, contracting, billing setup review, and compliance assessment. Completion does not guarantee payer approval, network participation, contract acceptance, reimbursement, or effective dates.

Choose Signature Method

Draft is stored locally until backend connection is configured.
✓

Thank You!

Your Behavioral Health, Psychiatry, Psychology, ABA & Substance Use Client Discovery Form has been submitted successfully.

Your form is currently in review.

Our Credentialing team will review your information and supporting documentation and contact you if additional information is required.

Organization:

Application Reference:

Maximize Your Revenue. With Expert RCM Services

Book Your Free Consultation NowVector

Schedule a consultation today to achieve financial success and regulatory compliance. Let us help you improve patient outcomes while increasing your revenue.