Master Level Counselor Provider Account Application {F800-053-000}

STATE OF WASHINGTON DEPARTMENT OF LABOR AND INDUSTRIES Crime Victims Compensation Program PO Box 44520 · Olympia, Washington 98504-4520 Dear Provider: If you choose to become an established provider with us, please complete the enclosed provider application and return it to us at your earliest convenience. Upon registration, you will receive your provider account number and a packet of information related to billing our program for your services. We have published a mental health fee schedule which is available on our website, www.CrimeVictims.Lni.wa.gov. If you have any questions related to our reimbursement rate you may contact our toll free number. The Crime Victims Compensation Program (CVCP) is currently reimbursing providers a percentage of the billing rates used by the Department of Labor and Industries. Our program is the last payer of benefits. Crime victims must first use any private or public insurance they have before the CVCP can pay. If you are currently treating a crime victim with an allowed claim and choose not to conduct further business with us, you cannot bill the victim for services you have provided thus far. To be paid for treatment provided to date, you will need to complete the enclosed provider application agreement and submit it along with your bills to the CVCP for payment consideration. We will assign a provider account number for bill processing purposes. After the bills have been processed and you receive your remittance advice, you may contact us to terminate your account. If at any time you decide not to accept crime victims as patients, please refer them to our toll free number (1-800-762-3716) for a listing of CVC registered providers located in their area. Sincerely, The Crime Victims Compensation Program F800-053-000 Cover letter 5-2011 American LegalNet, Inc. www.FormsWorkFlow.com MASTER LEVEL COUNSELOR APPLICATION INSTRUCTIONS NOTICE: Each applicant must complete an application. A number will be issued to each individual provider. If additional copies are needed, copy all portions of the application from the internet or call (360) 902-5377. Photo copies can be made of this application for completion. SECTION I: TO BE COMPLETED BY ALL PROVIDERS Enter the Tax Payer Identification Number (EIN or SSN). The number you will use to report earnings to the IRS - This must match the information on the W-9. SECTION II: TO BE COMPLETED BY ALL PROVIDERS A. Administrative Information 1. Enter the name of the business you wish to submit your bills and have your account set up as, (DBA). 2. Enter the phone number of the business. 2a. Enter the fax number of the business. 3. Enter the billing address as it appears on your bills submitted to Crime Victims Compensation Program and where payments should be mailed. 4. Enter the physical address of the business. 5. Enter the contact person's name ­ person who can answer questions regarding your bills or your account. 6. Enter the billing phone number where we may call to ask questions regarding your bills or your account. 7. If you will be attached to a group, please provide group number (for billing purposes). B. Individual or Organization Information ­ Complete all applicable information 1. Enter the name of the individual or organization providing services to injured workers. 2. Enter the type of service(s) provided. 3. Enter your license, certification or registration number. 4. Enter the date the license, certification or registration was issued (month, day and year). ATTACH COPY 5. Enter the date the license, certification or registration will expire (month, day and year). 6. Enter the state where the license, certification or registration was issued. C. National Provider Identifier (NPI) Information 1. Enter the individual or organization name. 2. If application is for a subpart, enter subpart name. 3. Check one. Type I ­ individual counselor Type II ­ mental health clinics. 4. Enter the address associated with the NPI number you have provided. 5. Enter the NPI 10-digit identifier. 6. If application is for a subpart, enter the subpart NPI 10-digit identifier. 7. Enter the taxonomy codes of the individual, organization or subpart. If more than six, please list on a separate sheet of paper. * Each January the Internal Revenue Service requires us to send a completed Form 1099 MISC reporting payments of $600.00 or more made to a Federal Tax Identification Number (EIN or SSN) during the last calendar year. If you received payments from more than one department program, you may receive more than one Form 1099 Misc. Please Do Not Forget To Read and Sign The "Provider Agreement" F800-053-000 Provider Application & Notice 6-2009 American LegalNet, Inc. www.FormsWorkFlow.com Master Level Counselor Provider Account Application Return To: Provider Registration Crime Victims Compensation Program Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520 (360) 902-5377 FAX (360) 902-5333 (Please type or print clearly on all sections) Please check: New Provider Address Updates for Reactivation of Provider Account Tax ID Change ­ Effective Date _______________ Required Internet address: http://www.lni.wa.gov/FormPub I. TAX REPORTING INFORMATION Tax Payer Identification Number (EIN or SSN) THIS NUMBER MUST MATCH THE W-9 FORM YOU SUBMIT Unless otherwise notified, your claims related correspondence will go to your business (physical) address. Please 2. 4. II. ACCOUNT AND BILLING INFORMATION A. Administrative Information 1. 3. check if you would like all mail to go to the billing address. Business name (as you wish to submit your bills and have your account set up, DBA) Billing address (as it appears on your bills submitted to CVC and where payments should be mailed) Business phone# 2a. Business FAX# Business address (the physical location of the business) 5. Contact person's name 6. Billing phone# (where we may call regarding your account/bills) 7. CVC group payee provider # B. Individual or Organization Information ­ Attach copy of current license 1. 3. Provider's name (Last, First, MI) Professional license/certification/registration number 4. License issue date 5. 2. Specialty / Services provided 6. State where issued License expiration date C. National Provider Identifier (NPI) Information 1. Individual or Organization name 4. NPI address 5. NPI 10-digit Identifier __ __ __ __ __ __ __ __ __ __ 7. Taxonomy Codes __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ 6. If for Subpart, provider Subpart