Credentialing
The Child and Adolescent Mental Health Division (CAMHD) Credentialing forms listed below are for contracted agency use only. Individual service providers must contact their employer’s Credentialing section to request a CAMHD credentialing packet. Direct submissions of the CAMHD Credentialing forms to the CAMHD Credentialing Section will not be processed.
Credentialing Forms
Paraprofessional (Para) & Mental Health Professional (MHP) Forms
- CAMHD – Para & MHP Agency Credentialing Packet – 2020.03.24 eSignatures
- PARAPROFESSIONAL PROVIDER CHECKLIST Rev. 9-2021 – Sample
- MHP PROVIDER CHECKLIST – Rev. 9-2021 – Sample
Qualified Mental Health Professional (QMHP) Forms
- CAMHD – QMHP CAMHD Credentialing Packet – 2020.03.24 eSignatures
- QMHP PROVIDER CHECKLIST – Revised 9-2021 – Sample
Abuse and Neglect Consent Forms
- Adult Protective Services (APS-DHS1507-0114)
- Child Protective Services (CAN/S 2020.03.24 eSignatures)
Other Forms
- Request to Change Form – Rev 02-2019 (Word Document Download)
- Attestation Letter Template_Rev. 10-2018 (Word Document Download)
- CMO Supplemental Form Rev. 04-2018 (PDF Document Download)
Credentialing Policies
- Delegation of Credentialing Primary Source Verification
- Initial and Re-Credentialing of QMHPs
- Initial and Re-Credentialing of MHPs and PARAs
- Child Abuse and Neglect Check
For instructions and/or questions about these credentialing forms, please contact the CAMHD Credentialing Section at (808) 733-9333 or email at [email protected].
Last reviewed on November 10, 2022