FHIPA Provider Eligibility Form

The Forest Hills IPA Inc. Security, Reliability & Professionalism

Preliminary Provider Eligibility Form

The Forest Hills IPA is a professionally managed, nationwide network of licensed mental health professionals and consultants. Our referral sources include insurers, IME companies, rehabilitation and claim services, self-insured companies, EAPs, and attorneys.

Adding your name to our provider network is as simple as filling out the form below. Qualified members in the continental United States are eligible for IME and peer review referrals in their specialty areas, and reserve the right to negotiate fees for services on a case-by-case basis. (Note: FHIPA does not handle treatment referrals.)

What's more, FHIPA assumes responsibility for payment of all provider fees -- so your valuable time is never wasted filling out complicated forms or making endless collection calls to vendors and insurers. Providers are paid in full within 30 - 45 days of receiving their final report and invoice.

Automatic Confirmation
You will receive automatic confirmation of your application on the computer screen once you submit the form below. Your name, location, and specialties are then automatically entered into our data base. If you do not receive confirmation on your screen, please notify us by e-mail. Additional required documentation (an up-to-date copy of your CV, proof of malpractice insurance, a copy of your license, and completion of a more detailed Provider Eligibility Form) will be requested when we contact you for your first referral.

If you have any questions regarding FHIPA provider membership or require additional information, please feel free to contact me at (718) 786-1328.

Sincerely,

Leonard Grossman Ph.D.,
President, The Forest Hills IPA Inc.
Diplomate, The American Board of Forensic Examiners

Preliminary Provider Eligibility Form

Note: Required Fields are in indicated in Red, and must be completed.

First Name: Last:

Office Address

Group:

Street: Suite:

City: State: Zip: County:

Phone: Fax: E-Mail:

Specialties and Certifications

Please check off all the specialties and certifications which apply to you:

licensed psychiatrist (board certified in psychiatry) (board certified in neurology)

certified in addiction medicine

certified in occupational psychiatry

licensed psychologist licensed neuropsychologist

Other:

Testing and IME Experience and Clinical Practice

MMPI testing
projective testing
psychodiagnostic testing
neuropsychological testing
insurance-related IME experience (disability, no-fault, workers compensation, liability, etc.)
insurance-related file review experience
willing to take cases which may require court testimony (and have prior experience)
currently in clinical practice in my specialty areas

Additional Information and Comments

How were you referred to us?

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