Submit Your Application!Complete the online application and our Changing Minds Credentialing Administrator contact you to started! Name * First Name Last Name Date of Birth [MM-DD-YYYY] * Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Licensure Type * Licensed Clinical Social Worker Licensed Marriage and Family Therapist Licensed Clinical Professional Counselor Licensed Drug and Alcohol Counselor NV State License Number * NPI Number * EHR System You Currently Use * Currently credentialed with: Are you currently sanctioned by Nevada Medicaid? * If you are currently sanctioned by Nevada Medicaid we are unable to contract with you at that this time. Yes No Subscription Type * Annual Subscription Monthly Subscription Insurances you want to be credentialed with: * AARP Anthem Commercial Anthem Medicaid Champva Aetna Cigna Ambetter Behavioral Health Options Humana HPN Medicaid HPN/SHL Commercial Medicaid of Nevada Molina Silver Summit Medicare UMR United Health Care TriCare West TriWest Alliance Upload Documents Below CAQH Registration ID# * If you haven't done it already, complete at https://proview.caqh.org/Login/Index?ReturnUrl=%2f CAQH Login * CAQH Password * Our Changing Minds Credentialing Administrator has received your documents and will contact you!For any questions or concerns, email Jamie@ChangingMindsPsych.COm Forms You Will Need Direct Deposit Form W9 Form
