MHA22b (REV 02‐2020) Page 1 of 6

Contra Costa County Behavioral Health Recredentialing Application

Incomplete applications may result in a delay in the recredentialing process

All Providers: Please include the following with the completed packet:

If you are a MD, DO or NP, please submit all documents listed above AND the following:

If you are a Registered Nurse, LPT, LMFT, LCSW, PhD-Licensed, or PsyD-Licensed, please submit all documents listed above AND the following:

If you are an AMFT or ASW, please submit all documents listed above AND the following:

If you are a newly qualified Pre-Doctoral- Waivered, PhD- Waivered, or PsyD- Waivered, please submit all documents listed above AND the following:

Note: If you are recreden aling as a PsyD‐ Waivered or PhD‐ Waivered, or Pre‐Doctoral‐ Waivered, your recreden aling period will be set to three years or the end of your waiver, whichever is sooner.

106H00000X -

1041C0700X -

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2084P0800X -

363LP0808X -

163W00000X -

163WP0809X -

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Licensed MFT Counselor or Registered AMFT

Licensed Social Worker or Registered ASW

Licensed Psychologist

Licensed Psychiatrist

Nurse Practitioner (Psychiatric/Mental Health)

Registered Nurse (Psychiatric/Mental Health)

Registered Nurse (Psychiatric/Mental Health/Adult)

Registered Nurse (Psychiatric/Mental Health/Child & Adolescent)

Clinical Nurse Specialist (Psychiatric/Mental Health)

Licensed Psychiatric Technician

Intern/Trainee (Student in an organized health care education/training program)

Counselor (Unlicensed Staff)

Recredentialing Form (MHA22b)- All applicable sections of the form must be complete. Also, if you answered “yes” to any of the attestation questions A-M, provide full details on a separate sheet of paper.

Social Security Number for Provider Credentialing and Recredentialing Form (MHA22c)

Copy of valid government issued photo identification (Driver’s License or Passport)

Copy of Degree (if obtained since your last credentialing)

Copy of NPI registration with valid taxonomy (Note: Taxonomy code must be designated as primary)

Copy of current DEA Registration

Copy of current Professional License

Copy of current Professional License

Copy of current Registration

If you are a newly qualified Trainee, please submit all documents listed above AND the following:

Executed agreement or contract between the agency and school

Field placement agreement signed by the student, individual supervisor and/or training coordinator and school fieldplacement liaison

Copy of Curriculum Vita or Resume

Copy of Official Transcript

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MHA22b (REV 02‐2020) Page 2 of 6

Submit completed packet to: Office of Provider Services

Email: BHRecredentialing@cchealth.org - or - Fax: (925) 608-6794

Section I: Reason for Submission To be completed by all providers 

3 Year Recredentialing – Providers are required to be recredentialed every three years.Check here if you are applying for recredentialing and complete sections I, II, III, IV, V, VI, VII, VIII, IX, and X.

Credentialing Category Change – Check here if you are requesting a review of your credentialing information to apply foran updated credentialing category. Complete the applicable sections listed below.

Section II: Identifying Information To be completed by all providers 

Check one (if known)

MHRS

DMHW

Administra ve Staff

LMFT

LCSW

PhD-Licensed

PsyD-Licensed

New LMFT, LCSW, PhD, or PsyD LicenseComplete Sections I, II, V, IX & X

New AMFT or ASW RegistrationComplete Sections I, II, III, VI, IX & X

Additional EducationComplete Section I, II, III, IX, & X

Apply for Waivered PsychologistComplete Sections I, II, III, VI, IX & X

Apply for TraineeComplete Sections I, II, III, VII, IX & X

Additional Work ExperienceComplete Section I, II, VIII, IX, & X

Provider Type:

Contra Costa County Behavioral Health RECREDENTIALING APPLICATION

Reactivation of ShareCare ID – If your ShareCare ID was inactivated more than 30 days ago due to a change in youremployment AND you are within your 3 year credentialing period, complete sections II, III, IV, V, VI, VII, VIII, IX, and X.If less than 30 days, use the Credentialing Change Form. If you are no longer within your 3 year credentialing period, usethe Credentialing Form.

AMFT

ACSW

Pre-Doc Waivered

PhD-Waivered

PsyD-Waivered

Trainee

Unlicensed Worker

MD/DO

NP

RN

LPT

Current Home Address City State Zip Date Range:

Previous Home Address (if moved within last three years) City State Zip Date Range:

Current Agency/Employer Name: Facility/Program ID:

First Name (please use full legal name) Middle Name Last Name Jr., Sr., M.D., etc

ShareCare ID Previous Name (maiden name, etc) Date of Birth (MM/DD/YYYY)

Driver’s License Number State Expira on Date NPI Number Taxonomy Code– see codes on pg 1

Medi‐Cal# (if applicable) Medicare # (if applicable) Professional License or Registra on # (if applicable) Expira on Date

Send credentialing confirmation to: Name: _______________________________ Email: ____________________________

This form is only intended for the actions listed above.

For new providers, use the Staff Number Assignment Worksheet and Credentialing/Privileging Form. For facility changes and legal name changes, use the Credentialing Change Form. All forms can be downloaded from: https://cchealth.org/mentalhealth/provider/

MHA22b (REV 02‐2020) Page 3 of 6

Section III: Education N/A

Section IV: For Licensed Psychiatrists and Physicians Only N/A

Section V: For LMFT, LCSW, Ph-D Licensed, Psy-D Licensed, NP, and RNs Only N/A

Section VI: For Interns Only N/A

Have you become an intern since your last credentialing? If yes, check the appropriate box and attach applicable documentation. Note: Waivered Psychologists must obtain a DHCS waiver through the Office of Provider Services.

Registered AMFT or ASW - Attach a copy of your BBS registration.

Waivered Psychologist (PhD or PsyD) – Attach a copy of your resume and official transcript or degree. Note: If you arepre-graduation, you must complete a minimum of 48 semester/trimester units or 72 quarter units of graduate work.

Section VII: For Trainees Only N/A

Currently enrolled in: Master’s Degree Program - or - Doctoral Degree Program

School: _____________________________________________________________________________

Major: ___________________________________________ Start Date of Enrollment: ____________

Have you obtained additional education or training since your last credentialing that may change your credentialing status?

If yes, complete the section below and attach a copy of an official degree, transcript, or school verification letter for education completed in a mental health or a closely related field. You may also include information on any relevant training or certificates.

Associate’s Degree Bachelor’s Degree Master’s Degree Doctoral Degree

School Name Date Range of Enrollment

Major Year Degree Conferred

Other training or cer ficate Date A ended

Please answer the questions below and attach a copy of your professional license, DEA certificate, and NPI registration.

DEA Number: ________________ DEA Expiration Date: ________________

Are your hospital and clinic privileges currently in good standing? Yes No

Are you board certified or board eligible in Psychiatry? Yes No

Have you become licensed since your last credentialing? If yes, check the appropriate box and attach a copy of your professional license and NPI registration.

LMFT LCSW Ph-D Licensed Psy-D Licensed NP RN

Have you enrolled in a Master/Doctoral degree program in a Mental Health or closely related field since your last credentialing? If yes, check the appropriate box and attach a copy of:

Executed agreement or contract between agency and school – and –

Field placement agreement signed by (a) student, (b) supervisor and/or training coordinator, and (c) school fieldplacement liaison.

Section VIII: Employment Information (For Unlicensed Workers Only) N/A

Unlicensed staff is privileged based on both education and level of experience. Have you obtained additional work experience in a mental health setting since your last credentialing that may change your credentialing status? If yes, complete the section below. Note: A resume or supporting documentation may be attached, but may not be used as a substitute for completing this section.

Employer Name Job Title

Employer Address (Street Address, City, State, Zip)

Supervisor Name Supervisor Phone

Full Time Part TimeIf part me, how many

hours worked per week: __________ Date Range of Employment Total Time in Posi on (Years/Months)

MHA22b (REV 02‐2020) Page 4 of 6

Section IX: Signature To be completed by all providers

I hereby affirm that the information submitted in this application and any addenda hereto is true, current, correct, and complete and is furnished in good faith. I understand that material omissions or misrepresentations may result in denial of my application or termination of my privileges or employment.

Print Full Name: ________________________________________________________________________________

Signature: _____________________________________________________ Date: __________________ (Stamped or Electronic Signature Is Not Acceptable)

From: To:

Typical Duties:

MHA22b (REV 02‐2020) Page 5 of 6

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Section X: Attestation Questions: To be completed by all providers 

Please answer the following questions.

If your answer is “yes” to any of the questions A-M, please provide full details on a separate sheet of paper.

A. Has your license to practice in any jurisdiction, your Drug Enforcement Administration (DEA)registration or any applicable narcotic registration in any jurisdiction ever been denied, limited,restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have youvoluntarily or involuntarily relinquished any such license or registration or voluntarily orinvoluntarily accepted any such actions or conditions, or have you been fined or received a letterof reprimand or is such action pending?

Yes No

B. Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subjectedto probationary conditions, restricted or excluded, or have you voluntarily or involuntarilyrelinquished eligibility to provide services or accepted conditions on your eligibility to provideservices, for reasons relating to possible incompetence or improper professional conduct, orbreach of contract or program conditions, by Medicare, Medicaid, or any public program, or is anysuch action pending?

Yes No

C. Have your clinical privileges, membership, contractual participation or employment by anymedical organization (e.g. hospital medical staff, medical group, independent practice association(IPA), health plan, health maintenance organization (HMO), preferred provider organization(PPO), private payer (including those that contract with public programs), medical society,professional association, medical school faculty position or other health delivery entity or system),ever been denied, suspended, restricted, reduced, subject to probationary conditions, revoked ornot renewed for possible incompetence, improper professional conduct or breach of contract or isany such action pending?

Yes No

D. Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request formembership or clinical privileges, terminated contractual participation or employment, or resignedfrom any medical organization (e.g., hospital medical staff, medical group, independent practiceassociation (IPA), health plan, health maintenance organization (HMO), preferred providerorganization (PPO), medical society, professional association, medical school faculty position orother health delivery entity or system) while under investigation for possible incompetence orimproper professional conduct, or breach of contract, or in return for such an investigation notbeing conducted, or is any such action pending?

Yes No

E. Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquishyour status as a student in good standing in any internship, residency, fellowship, preceptorship,or other clinical education program?

Yes No

F. Has your membership or fellowship in any local, county, state, regional, national, or internationalprofessional organization ever been revoked, denied, reduced, limited, subjected to probationaryconditions, or not renewed, or is any such action pending?

Yes No

G. To your knowledge, has information pertaining to you ever been reported to the NationalPractitioner Data Bank? Yes No

H. Have you been denied certification/recertification by a specialty board, or has your admissibility,certification or recertification status changed (other than changing from admissible to certified)? Yes No

I. Have you ever been convicted of any crime (other than a minor traffic violation)? Yes No

MHA22b (REV 02‐2020) Page 6 of 6

Section X: Attestation Questions (continued): To be completed by all providers 

Please answer the following questions.

If your answer is “yes” to any of the questions A-M, please provide full details on a separate sheet of paper.

K. In the past (5) years, have you had a history of chemical dependency or substance abuse thatmight adversely affect your ability to competently and safely perform essential functions of apractitioner in your area of practice.

Yes No

L. Do you have an ongoing physical or mental impairment or condition which would make youunable, with or without reasonable accommodation, to perform the essential functions of apractitioner in your area of practice, or unable to perform those essential functions without directthreat to the health and safety of others.

Yes No

M. Have any judgments/arbitration or claims been entered against you, or settlements been agreedto by you within the last (7) years, in professional liability cases, or are there any filed and servedprofessional liability lawsuits/arbitration’s against you pending?

Yes No

N. Have you completed all continuing education requirements, as required by your licensing board? Yes No

N/A

O. Have you reviewed and completed the Contra Costa County Mental Health Plan BeneficiaryProtection Training within the last 3 years?The training must be completed at the time of initial credentialing and again every 3 years atrecredentialing. The training is available on the Provider Services Website (https://cchealth.org/mentalhealth/provider/).

Yes No

J. Are you currently engaged in the illegal use of drugs? (“Illegal use of drugs” means the use ofcontrolled substances, obtained illegally, as well as the use of controlled substances which arenot obtained pursuant to a valid prescription or not taken in accordance with the direction of alicensed health care practitioner. “Currently” does not mean on the day of or even the weekspreceding the completion of this application, rather, it means recently enough so that the illegaluse may have an impact on one’s ability to practice).

Yes No

I hereby affirm that the information submitted in the Attestation Questions, and any addenda thereto is true, current, correct and complete to the best of my knowledge and belief and is furnished in good faith. I understand that intentionally withholding or omitting material information or intentionally submitting material false or misleading information may result in denial of my application or termination of my privileges or employment.

I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics and other qualifications and for resolving any doubt about such qualifications.

During such time as this application is being processed, I agree to update the application should there be any change in the information provided.

Print Full Name: _____________________________________________________________________________

Signature: __________________________________________________ Date: ___________________ (Stamped or Electronic Signature Is Not Acceptable)

Submit completed packet to: Office of Provider Services

Email: BHRecredentialing@cchealth.org -or - Fax: (925) 608-6794

MHA22c (REV 02‐2020)

Submit completed form to: Office of Provider Services

For New Providers (Initial Credentialing): Email: provider.services@cchealth.org - or - Fax: (925) 608-6794

For Existing Providers (Recredentialing):

Email: bhrecredentialing@cchealth.org - or - Fax: (925) 608-6794

Contra Costa County Behavioral Health

Social Security Number for Provider Credentialing and Recredentialing

Provider’s Legal Name: Last: _______________________________ First: ___________________ Middle: _______________ Birth Date: ____________ NPI Number: _________________ ShareCare ID: ___________ (MM/DD/YYYY) (if known)

Social Security Number: ____________________________                          

Section I: Identifying Information

I authorize CCMHP to use my Social Security Number for purposes of identification when corresponding with the National Provider Data Bank and checking the Social Security Administration’s Death Master File.

Print Name: ___________________________________________ Signature: ____________________________________________ Date: ______________ (Stamped or Electronic Signature Is Not Acceptable)

Section II: Signature

Contra Costa Mental Health Plan (CCMHP) is required to conduct federal exclusion database checks at the time of credentialing and recredentialing providers. This includes querying the Social Security Administration’s Death Master File and National Practitioner Data Bank. These two database checks require the provider’s Social Security number. Below is a form to authorize the Provider Services Staff of the Contra Costa County Behavioral Health Division to use your Social Security number for these two required federal exclusion database checks.