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Outpatient Behavioral Health Agency Providers: Individual Rendering Provider Enrollment Information
September 13, 2011
PV Types:
110 – Outpatient Mental Health Clinic
111 – Community Mental Health Center (CMHC)
114 - PACT
118 – Mental Health – DMHSAS
This communication only applies to OPBH agency providers:
Very important: Make sure you fax all of the required documents when you complete the electronic provider enrollment form. The provider enrollment department processes the application based on receipt of the required fax.
The individual staff have to sign the provider agreement. There is no exception to the staff signature requirement.
Under Supervision for Licensure:
License Number: TEMP
Original Issue Date: List the start date of the board approved supervision agreement.
Expiration Date: The estimated end date for the supervision.
Required Document to Fax: The licensure department’s approved supervision agreement.
For questions, please contact Provider Enrollment: (800)522-0114 Option 5. Thank you.
Erin Meyer
