CBHNP

Licensed Psychologist Attestation LSW, LCSW, LPC, LMFT and Non-Licensed Practitioners I, ________________________________________ intend to employ the following person, an LSW, LCSW, LPC, LMFT or unlicensed masters level practitioner to see CBHNP HealthChoices Members and bill using my Medical Assistance Identification Number: Name: License Type, if applicable: I affirm that these persons will be used in accordance with PA Code, Chapter 41.58, State Board of Psychology, which states psychologists licensed by the Board may employ professional employees with graduate training in psychology, who shall perform their duties under the full direction, control and supervision of a licensed psychologist And according to Policy Clarification RFP11-97-66 & RFP 3-96- 181, which permits billing for applicable services rendered under the practitioners MAID in the HealthChoices program. I recognize for the purpose of billing CBHNP, a licensed psychologist is only permitted to supervise three (3) FTE clinicians. I recognize that I may employ licensed Clinical Social Workers, Licensed Social Workers, Licensed Professional Counselors and Licensed Marriage and Family Therapists as well as unlicensed practitioners. I further attest that; 1) I have verified this individuals highest level of education at the primary source. ___________ Initial Here 2) I have verified that this person meets all requirements outlined in PA Code Chapter 41 _________ Initial Here 3) I have verified that this individual has no Medicare or Medicaid sanctions against him/her _______ Initial Here 4) This individual will not be see CBHNP Members until notified of CBHNP approval ________ Initial Here 5) I assure that staff I am supervising have received proper training and will receive ongoing supervision per PA Code Chapter 41 __________ Initial Here 6) I have provided CBHNP, a current resume outlining the individuals work history __________ Initial Here _______________________________ ___________________________ _____________ Psychiatrist /Licensed Psychologist Signature License Number & Type Date

CBHNP Use: Verified by:__________________________________________ Date:______________________ Provider Notification Date:__________________________________________________________

Method of notice: FAX (keep coversheet confirming deliver attached) Mail (keep letter attached)