WORK WITH US - BEHAVIORAL HEALTH

Become a Health Plan of Nevada, Sierra Health and Life or Behaviorial Healthcare Options behavorial health provider. Complete the form below and we'll be in touch.

If you are a group, please include a completed Group Roster form. Download the form

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Practice/Group Information

Practice or Group Name:

The Practice or Group Name: field is required

Practice Address:

The Practice Address: field is required.

Office Phone:

The Office Phone: field is required.

Office Fax:

Tax Identification:

The Tax Identification: field is required

Contact Person:

The Contact Person: field is required

Email Address:

The Email Address: field is required.

Website

Services Provided:

The Services Provided: field is required

Population Served:

The Population Served: field is required

Provider Type:

Practitioner Information

Please complete the below section if you are a sole practitioner, if not, please continue to Count of Clinical

Provider Name:

Provider Licensure:

CAQH ID# (if applicable):

Count of Clinical

# of Licensed Clinical Staff:

# of Interns:

# of Approved Supervisors:

# of PSR/BST Staff:

If you are a group, please include a completed Group Roster form.

Will you be submitting a Group Roster form?

Yes No

Additional Staff Roster Information

Upload completed Group Roster form

Upload additional completed Group Roster form (if needed):

Upload business license(s)

Upload additional business license(s)

You have completed the letter of interest.
Once submitted, the review process will be completed within 14 business days.

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WORK WITH US - BEHAVIORAL HEALTH

Practice/Group Information

Practitioner Information

Count of Clinical

Additional Staff Roster Information