This information is being requested to meet regulatory requirements of the California Department of Managed Health Care. If you have questions, please contact us at 1-800-430-0535, option #4.

THIS IS NOT A CREDENTIALING APPLICATION

* Required Field

Provider Identity

Unique Provider ID/MIS: *

Agency/Entity:

Specialty Services

Please check the boxes corresponding with the illness(es) for which you feel competent to render services. Check all that apply:*

^†A child with serious emotional disturbances is defined as a child who has one or more mental disorders (other than substance abuse or developmental disability) as identified in the most current Diagnostic and Statistical Manual of Mental Disorders, and who meets the requirements of the Welfare and Institutions Code Section 5500.3(a)(2). (To read this section online, go to www.leginfo.ca.gov.)

Practice Address #1

Please document your routinely scheduled hours each day available for client appointments, regardless of payor. Account for breaks in your daily schedule and indicate "Closed" as needed.

Hours of Service: *

How many hours are available for appointments for clients of Human Affairs International of California and Magellan Health Services of California - Employer Services: (Provide the total number of hours per week you are available to see Magellan members at this location - your answer should include the hours per week you are seeing existing Magellan members, plus any hours you can make available for new Magellan patients.) * (hours:minutes)

Is the office at the address listed above wheelchair-accessible? Yes No

If not, describe the arrangements you make to meet with clients who are physically disabled: You have characters left.

Practice Address #2

Please document your routinely scheduled hours each day available for client appointments, regardless of payor. Account for breaks in your daily schedule and indicate "Closed" as needed.

Hours of Service:

How many hours are available for appointments for clients of Human Affairs International of California and Magellan Health Services of California - Employer Services: (Provide the total number of hours per week you are available to see Magellan members at this location - your answer should include the hours per week you are seeing existing Magellan members, plus any hours you can make available for new Magellan patients.) * : (hours:minutes)

Is the office at the address listed above wheelchair-accessible? Yes No

If not, describe the arrangements you make to meet with clients who are physically disabled: You have characters left.

Practice Address #3

Please document your routinely scheduled hours each day available for client appointments, regardless of payor. Account for breaks in your daily schedule and indicate "Closed" as needed.

Hours of Service:

How many hours are available for appointments for clients of Human Affairs International of California and Magellan Health Services of California - Employer Services: (Provide the total number of hours per week you are available to see Magellan members at this location - your answer should include the hours per week you are seeing existing Magellan members, plus any hours you can make available for new Magellan patients.) * : (hours:minutes)

Is the office at the address listed above wheelchair-accessible? Yes No

If not, describe the arrangements you make to meet with clients who are physically disabled: You have characters left.

Practice Address #4

Please document your routinely scheduled hours each day available for client appointments, regardless of payor. Account for breaks in your daily schedule and indicate "Closed" as needed.

Hours of Service:

How many hours are available for appointments for clients of Human Affairs International of California and Magellan Health Services of California - Employer Services: (Provide the total number of hours per week you are available to see Magellan members at this location - your answer should include the hours per week you are seeing existing Magellan members, plus any hours you can make available for new Magellan patients.) * : (hours:minutes)

Is the office at the address listed above wheelchair-accessible? Yes No

If not, describe the arrangements you make to meet with clients who are physically disabled: You have characters left.

Practice Address #5

Please document your routinely scheduled hours each day available for client appointments, regardless of payor. Account for breaks in your daily schedule and indicate "Closed" as needed.

Hours of Service:

How many hours are available for appointments for clients of Human Affairs International of California and Magellan Health Services of California - Employer Services: (Provide the total number of hours per week you are available to see Magellan members at this location - your answer should include the hours per week you are seeing existing Magellan members, plus any hours you can make available for new Magellan patients.) * : (hours:minutes)

Is the office at the address listed above wheelchair-accessible? Yes No

If not, describe the arrangements you make to meet with clients who are physically disabled: You have characters left.

Client Services

Are you accepting new clients?* Yes No

If yes, how many new clients can you accept per month?

Can you see emergent/urgent clients on a same-day basis? Yes No

Are you routinely available to see clients at least four full days a week? Yes No

What is the average waiting time to obtain an appointment? : (hours:minutes)

What provisions do you make for client calls outside your normal business hours? Answering Machine/Voice Mail Cell Phone/Pager Live Answering Service

Do you provide routine appointments within 10 business days of request? Yes No

Are you available to provide urgent care within 48 hours? Yes No

Are you available to provide emergency care within 6 hours? Yes No

Practice Information

The following practice information is provided to support the referral process.

a. Please check area(s) within your scope of practice for which you have training and expertise, and for which you are accepting referrals. A minimum of one (1) selection is required in both the General Categories and Age Categories. In addition, indicate within the General and Age categories the approximate percentage of your practice that area represents. The total within each category should add to 100%*.

• First- select: Check area(s) within your scope of practice for which you have training and expertise, and for which you are accepting referrals. Indicate your selections in the check box to the left of the practice area.
• Then - rank: Select five (5) of the areas where you've indicated particular expertise and rank order these "1" to "5" with "1" being greatest expertise of the five areas identified. Indicate your ranking in the "Rank" column to the right of the practice area.

Provider Languages

Please identify the languages in which you are fluent and can conduct treatment.*

English (Native Speaker) Yes No

Native Speaker of other language(s):

Voluntary Information

Providing the information below is voluntary.
The information is used for referrals and for compliance with Title VI of the 1964 Civil Rights Act. If you provide this information, you are consenting to its use and disclosure to clients who request a referral to a provider of a particular gender or ethnic background and to the use of the information on websites and in provider directories published by Magellan and our customers. The information also will be used for statistical and marketing purposes concerning the diversity of the behavioral health provider network.

Gender: Male Female

Attestation

I hereby certify that all information I have submitted is correct and complete. I further understand that any information I provide to Magellan Health Services‡ that subsequently is found to be false could result in termination of any contract I may enter into with Magellan Health Services or its affiliates.

I Agree *

‡ Magellan Health Services does business in California as Human Affairs International of California and Magellan Health Services of California, Inc. - Employer Services