Provider Registration

Name

This field is for validation purposes and should be left unchanged.

Practice Information

Practice Name*

Clinician Specialty*

Clinician Specialty - Other

Clinician Credentials*

Clinician Credentials - Other

Provider NPI*

Enter the NPI number (letters and numbers accepted)

Preferred Call Back Number*

Mobile Number (Required if opting-in for SMS messaging)

Clinician Email*

Additional Clinicians

Clinician Name	Clinician Specialty	Clinicial Credentials - Other	Clinician NPI #	Clinician Email	Actions

There are no Clinicians.

Practice Phone Number*

Practice Mailing Address

City

State

Zip

County

By signing below, I acknowledge that I understand and agree to the following:

As part of Statewide Psychiatry Access, Resources and Knowledge (SPARK), child and adolescent psychiatrist, adult psychiatrists, addiction medicine specialists, maternal mental health specialists, and other licensed mental health professionals engage with primary care providers (PCPs) to help strengthen their ability to manage behavioral health needs of their pediatric and/or adult patients. Through telephone and video consultations with PCPs, SPARK psychiatrists and licensed mental health professionals, can assist, educate, and train registered PCPs in the care of their patients. SPARK psychiatrists and licensed mental health professionals do not establish provider-patient relationships with or prescribe medications for the patients of registered PCPs, but rather, provide services solely and directly to PCPs (provider-to-provider). Accordingly, PCPs will be exclusively responsible for providing clinical services in the exercise of their professional medical judgment.

As a participant in SPARK, PCP collaboration holds a critical role in maximizing the benefits of the psychiatry and mental health access program. As such, SPARK expects PCPs will participate in meaningful ways, including periodically participating in data collection related to the outputs and outcomes of the program. This includes basic demographic data about the PCP and practice information as it relates to SPARK. As part of the program, data about patients may be communicated with SPARK staff and PCPs agree to inform patients of this consultative effort and de-identify private health information prior to requesting and throughout consultation with SPARK consultants. If a patient declines to have provider-to-provider consultation on their behalf or their child or adolescent’s behalf, it is expected that the PCP will not seek consultation with regard to that specific patient. No patient private health information will be reported in this study. Patient demographic data, provider demographic data, provider needs data, and program outcomes, outputs, and impacts data will be collected and reported.

Risks in participating in this program are minimal and limited to typical daily medical personnel experiences (e.g., identification of child abuse, sensitive topics). Participation in this program can provide benefits such as increased knowledge and competency, specialty consultation for specific patient care, patient referral assistance, and provider wellness. Individual patients, by proxy, can benefit by improved access to mental health care and mental health wellness via increased and improved mental health screening, diagnosis, treatment, and referral.

Signature*