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

Last reviewed on November 10, 2022