Clinical Social Workers & Marriage and Family Therapists - Client Discovery Form

Client Discovery Form

Clinical Social Workers & Marriage and Family Therapists

Purpose: This form collects provider, practice, services, location, documentation, payer, supervision, compliance, and enrollment details needed to assess Medicare/Medicare Advantage where applicable, Medicaid, Medicaid MCO, Commercial plans, EAP networks, and provider enrollment requirements for LCSW, LMFT, and related behavioral health providers.

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. Upload supporting documents through the secure upload fields only. Do not email protected or sensitive documents. Use Additional Notes for payer-specific concerns, special contracting requests, or enrollment barriers.

1. Primary Client Contact & Organization Information

Primary Service Location *

Secondary Contact, if available

2. Key Identifiers

State(s) of Licensure *

3. Scope of Work

Services Purchased / Requested *
Target Payer Categories *Select all that apply. Detail fields open for payer categories that require additional information.
State(s) for Enrollment *

4. Key Project Information

New, Existing Practice, or Acquisition?

5. Provider Type / Credentials

6. Behavioral Health Services Offered

A. Psychotherapy / Counseling Services

B. Populations Served

C. Treatment Modalities / Clinical Focus Areas

D. Service Delivery Methods

7. Locations & Service Delivery Information

States Where Telehealth Is Provided

Hours of Operation

8. Provider Billing & Coding Information

Common CPT Codes Used

Common Place of Service Codes Used

9. Provider Enrollment Roster

Complete one record per LCSW, LMFT, associate / provisionally licensed clinician, or related behavioral health provider requiring payer enrollment or credentialing.

10. Existing Provider Enrollment

11. Supervision, Collaborative Providers & Staff

Supervision Notes

12. Compliance Protocols

13. Additional Notes / Special Considerations

14. Upload Supporting Documents

Documents containing protected health information, personally identifiable information, or other sensitive data must be uploaded only through the approved secure process and should not be sent through unsecured email.

Provider-Level Documents

Entity / Practice Documents

15. Client Acknowledgements, Signatures & Certification

Privacy, Confidentiality, and Security of Credentialing Documents

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

Technology Platform Usage Requirements

All credentialing documents required to complete the credentialing process must be uploaded directly by the Client through the designated secure upload portal during onboarding and ongoing workflow as applicable.

CAQH or ADA / Provider Profile Access

If the Client is not willing or able to provide access to applicable provider profiles, TriumpHealth is not responsible for application denials, delays, or payer issues caused by incomplete profiles, missing attestations, or unavailable provider information.

Primary Location Address

The Client verifies that the primary location address provided is accurate and is not a virtual office, mail drop, P.O. Box, mailbox service, or other address that fails to meet payer requirements, unless specifically permitted by payer rules.

Pricing Terms

Pricing and continued processing are contingent upon the Client providing accurate information, required access, and requested documents in a timely manner consistent with the signed agreement and TriumpHealth onboarding requirements.

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.
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