|This document is for downloading as a hard
copy Professional Information Questionnaire
The American Mental Health Alliance- Oregon
PO Box 4075
Section I: Contacting you.
Section II: Insurance InformationProfessional liability/malpractice insurance carrier:
Liability/Malpractice expiration Date:
Coverage limits per incident and aggregate claims:
Per incident coverage:
PLEASE SUBMIT PROOF OF LICENSURE AND A COPY OF THE FACE SHEET OF YOUR MALPRACTICE INSURANCE WITH THIS QUESTIONNAIRE
Section III: Education and Training
(AMHA-OR Membership requires a valid license for independent clinical practice. If you more than one such license please specify which you prefer to be indexed by in the records.)
1. Undergraduate Education
2. Graduate Education:
3. Internship/Residency Training:
4. Post Graduate Training:
What special or specific clinical areas of expertise and/or interests do you have that you would like AMHA-OR to be aware of?
[ AMHA-OR may from time to time be called upon to provide experts or specialists to the media or as consultants in legal matters, it is from] your note here that we will be able to call upon you. If you have no interest in answering media or legal questions, leave this area blank. ]
Section IV: Your Current Clinical Practice
1. Populations Served: (check all that apply)
2. Clinical Modalities: (check all that apply)
3. Clinical Treatment Orientations: (check all that apply)
4. Areas of Clinical Focus: (check all that apply)
What diagnostic categories(or categories of people) are you especially qualified to treat?
Do you practice or have recent experience in hospital settings providing any of the following:
(Yes) (No) Do you have special expertise working with suicidal people?
(Yes) (No) If yes, are you willing to provide consultation to AMHA-OR clinicians who have concerns about suicidality in a patient?
(Yes) (No) Currently how many direct service clinical hours do you work per week?
(Check only one answer if possible)
In what settings do you work? (Check all that apply)
5. Please provide estimates to the following inquiries regarding your clinical practice:
6. Supervision/consultation: (circle whichever applies)
Section V: Practice ReviewWe appreciate that information provided within this section may be of a sensitive nature. AMHA-OR will treat all information provided here as confidential to the fullest extent allowable by law. The AMHA-OR representatives reviewing your responses will hold them confidential and will use your responses solely for safeguarding the interests of AMHA-OR and those to whom AMHA-OR contracts services.
(Circle yes or no to each question)(Yes) (No) Do you have any limitation or disability that requires special considerationor accommodation in order to practice? (e.g. chronic illness, physical impairment, mental illness, etc.) (Yes) (No) Are you or have you been subject to: (Yes) (No) Discipline by a professional organization? (Yes) (No) Suspension, limitation or revocation of hospital practice? (Yes) (No) Sanction from Medicare, Medicaid, Workers Compensation or CHAMPUS? (Yes) (No) Sanction from any HMO, PPO, or other third party provider? (Yes) (No) Civil action brought against you concerning your professional practice? (Yes) (No) Professional liability insurance cancellation? (Yes) (No) State license investigation, restriction, suspension, or revocation? (Yes) (No) Arrest or conviction of a felony? (Yes) (No) DEA license investigation, restriction, suspension, or revocation? (Yes) (No) Are there now any complaints, charges or investigations pending against you with any licensing boards or professional ethics bodies?Yes No (Yes) (No) Do you currently have any reason to believe that a civil action relating to your professional practice may be brought against you in the future?
Have you ever engaged in a sexual relationship with:
(Yes) (No) a current or former client? (Yes) (No) any person having a direct relationship to a current or former client?
If you have answered yes to any of the above questions, please provide an explanation of circumstances or special needs.
Section VI: Other Information about you.
Please write in the space below anything that you would like AMHA to know about you; i.e., foreign languages spoken, sign language capability, etc. Use additional sheets if necessary.
Section VII: Certification.
I, the undersigned, hereby attest that the information given in or attached to this application is accurate and complete. I specifically allow authorized representatives of AMHA-Oregon to consult with any third party that may have information bearing on the subject matter addressed by this application and to inspect or obtain any reports, records, recommendations, or other documents or disclosures of third parties that may be material to the questions in this application. I also specifically authorize any third parties to release information to authorized representatives of AMHA-Oregon upon request. I hereby release authorized representatives of AMHA-Oregon, and any third parties, from any liability for any reports, records, recommendations, or other documents or disclosures involving me that are made, requested, or received by AMHA-Oregons authorized representatives to, from, or by any third parties, including otherwise privileged or confidential information, made or given in good faith and relating to the subject matter addressed by this application.
PLEASE SUBMIT PROOF OF LICENSURE AND A COPY OF THE FACE SHEET OF YOUR MALPRACTICE INSURANCE COVERAGE WITH THIS QUESTIONNAIRE.
ANY INFORMATION ENTERED IN THIS APPLICATION THAT SUBSEQUENTLY IS FOUND TO BE FALSE COULD RESULT IN REFUSAL TO ENTER INTO A CONTRACT WITH YOU OR TERMINATION OF ANY CONTRACT WITH YOU.
YOUR SIGNATURE IS REQUIRED TO COMPLETE THIS APPLICATION.
STAMPED SIGNATURES ARE NOT ACCEPTABLE.
AMHA-OR does not discriminate on the basis of race, national origin, age, gender, disability, religious affiliation or sexual orientation We recognize the Americans with Disabilities Act.(Yes) (No) Do you want or require an accommodation under that law
With regard to referrals received by me through the AMHA-Oregon referral service:
I shall assume the risk of liability for, and shall indemnify, defend, protect and hold harmless the American Mental Health Alliance, Oregon hereafter referred to as the "Service" and it's officers, agents and employees from and against any and all claims, damages, suits, judgements, liabilities, losses, court costs and expenses, including attorney's fees, for all injury, sickness, disease, or damages arising out of, or in the course of accepting a referral or making a referral to another member by me or any of my agents or employees and for any acts or omissions in my treating or not treating patients referred to me by this Service. I also agree to keep my malpractice insurance in force until the statutes of limitations expire for the filing of malpractice claims associated with any client referred by this Service.
Without limiting the scope or the extent of the protection afforded the Service by the liabilities I have assumed in the preceding paragraph, I shall maintain in force for the life of this agreement, liability insurance to cover the liabilities I assumed in the preceding paragraph. I shall continue such coverage following termination of this agreement so as to afford protection to the Service. I shall also promptly notify the Service of any cancellation, reduction or other material change in the amount or scope of any coverage(s) required in this application.
I, __________________________________________________, agree that as a member of this Service that I will abide by all federal, state and local laws pertaining to practice in my area and to provide ethical and continuous care of all people referred to me by the Service. I agree to inform the directors of the Service in the event of any malpractice lawsuit filed against me or if there are any changes in the status of this Application. I agree that any referrals I receive from this service will be under my direct care and will not be directly referred to other providers without first consulting with the Network Director in writing. I also agree not to present myself to the community as a representative of the views and policies of this Service without first obtaining written permission from the Network Director. I understand that the membership fee will be utilized to cover the costs of training the referral resource counselors, paying employee's salaries, computer software, hardware, advertising expenses, secretarial fees, accounting costs and printing expenses.
This Service reserves the absolute right to remove any member from the referral list and/or cease referrals in the event of: loss or suspension or licensure, suspension or loss of DEA number, conviction of a misdemeanor or felony involving moral turpitude, disciplinary action taken by a professional society or by the suspension or loss of staff privileges at a hospital or report made by the hospital to the Board of Medical Quality Assurance, or any mental or physical incapacitation, any failure to adhere to the membership requirements or a member's failure to meet the standards of the Service, or omissions or false statements contained in this Application, or any breach of this contract, any failure to maintain insurance, or failure to practice in good faith and maintain a reasonable standard of care.
I swear that the information provided on this application form is true and accurate.
Print Name: ________________________________________________