TERM Applications

Instructions

Form W-9 (Rev. December 2014)
Request for Taxpayer Identification Number and Certification 2017-11-02
Instructions and FAQs Credentialing and Contracting (pdf)
2020-02-19
TERM Panel Speciality Criteria (pdf)
2018-06-22

Credentialing Application

1.1 Credentialing Criteria (pdf)
2020-01-30
Credentialing Application Instructions (pdf)
2020-02-26

TERM Therapist Applications

TERM Therapist Clinical Application (docx)
Revised 03/06/2020 2020-03-10
Writing Sample Packet for Therapist (docx)
2018-07-12

TERM Evaluator Applications

TERM Evaluator Clinical Application (docx)
Revised 03/06/2020 2020-03-10
Writing Sample Packet for Evaluators (pdf)
2018-07-10

Interns

Evaluator Intern Packet (docx)
2018-08-29
Therapy Intern Application (docx)
2018-08-29

Specialty Addition Applications

TERM Evaluator Provider: Specialty Addition Application (docx)
Revised 02/27/2020 2020-02-27
TERM Therapist : Specialty Addition Application (docx)
2018-07-11