PediPRN Provider Enrollment Form

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Email *

Provider Name:

Provider Title

Practice/Organization Name

Practice Type (pediatrics, family medicine, etc)

Practice Phone (back office preferred, not shared)

Office Manager (if applicable):

Office Manager Email (if applicable):

Submission Agreement

By submitting this form:

I agree to inform patients when I plan to engage the PediPRN program on their behalf and will share health information with PediPRN unless the patient declines the PediPRN services
I understand that consultations are educational in nature and that the calling providers are fully responsible for any and all clinical management decisions
I agree to continue to manage the behavioral health care of appropriate cases following case based consultation with the PediPRN team.
I agree to complete periodic satisfaction surveys.
I understand that the PediPRN psychiatric consultant will not be prescribing medications.

Submit

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