PARTICIPANT LOG IN

Want to grow your practice?

Want to build your practice through Coaching, Employee Assistance Program or Student Assistance Program referrals?

Then consider becoming an Espyr Network Provider.

Minimum Requirements:

  • Current state license/certification at the highest level in your state - 3 years post licensure
  • Malpractice insurance coverage of at least $1 million per incident and $3 million in aggregate
  • Ability to routinely serve new clients within three business days
  • Brief counseling, assessment and referral skills

If you are interested in joining our provider network, please complete the Provider Application below.  Once we review your application, we will contact you with next steps.

  • Please type or print legibly.

    If you have questions please call or email our Provider Relations Department at 800-522-1073 or providerrelations@espyr.com between 8:30am-5:00pm Eastern time, Mon.-Fri.

  • The information below is OPTIONAL and is only for the purpose of accommodating a stated client preference.
  • Independent Practice License

  • List below all states in which you are licensed for independent practice:
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • Malpractice Insurance

  • Date Format: MM slash DD slash YYYY
  • Date Format: MM slash DD slash YYYY
  • (in years)
  • Primary Office Information

  • (if applicable)
  • If applicable, or the contact person for your practice if not yourself:
    Espyr prohibits in-home offices
    All providers are required to have Crisis/Emergency Greetings
  • MondayTuesdayWednesdayThursdayFridaySaturdaySunday 
    Please indicate your actual practice hours each day at this location, e.g. 9:00am to 5:00pm.
  • Make checks payable to (name must match the tax ID owner name on file with IRS for the TIN listed below)
  • Secondary Office Information

  • (if applicable)
  • If applicable, or the contact person for your practice if not yourself:
    Espyr prohibits in-home offices
  • MondayTuesdayWednesdayThursdayFridaySaturdaySunday 
    Please indicate your actual practice hours each day at this location, e.g. 9:00am to 5:00pm.
  • Make checks payable to (name must match the tax ID owner name on file with IRS for the TIN listed below)
  • Street AddressSuite #CityStateZIP Code 
  • Please list the name of at least one substance abuse treatment program or facility, and one mental health program or facility to which you commonly refer clients in need of higher levels of care, or a specialized program such as a substance abuse IOP:
  • Please List Three Professional References

  • DISCLOSURE STATEMENTS

  • Attestation and Release

  • I hereby submit this application for participation with Espyr. I understand that this application will be reviewed based on the information I have provided herein. I understand and agree that the certifications, authorizations and other provisions contained herein shall remain in force for so long as this application is pending and, if accepted for participation, for so long as my participating Provider agreement with Espyr remains in force. I understand and consent that Espyr has sole authority to accept or deny my application, as a participating Provider, and that I will not appeal a denial of my application. If Espyr does not credential me as a Provider, I agree not to initiate legal action in response to such determination. I hereby certify that the information contained herein is correct, accurate and complete to the best of my knowledge and belief. I understand that misrepresentations or omissions from this application may be cause for denial or dismissal from Espyr’s Provider Network, now or in the future. I agree to promptly notify Espyr if there are any material changes in the information provided, whether prior to or after my acceptance as an Espyr participating Provider. By applying for participation in the Espyr Provider Network, I hereby authorize any hospital, agency or group practice, other clinical employer, professional society, malpractice carrier, or other agency or organization with information regarding my credentials to release, furnish copies, or give details of my professional credentials and qualifications related to my clinical practice, competence and qualifications, including my moral and ethical qualifications. I hereby release from liability any and all individuals and organizations that, in good faith and without malice, provide information to Espyr for the purpose of evaluating this application and release Espyr from liability for its use of the information it gathers in the application process. A photocopy of this permission will be as valid as the original. This authorization to obtain confidential information about me remains in effect until I notify Espyr otherwise in writing, or am no longer an Espyr participating Provider.
  • Date Format: MM slash DD slash YYYY
  • Questions about this application? Please call our Provider Relations Department at 800-522-1073 between 8:30am-5:00pm Eastern time, Mon. - Fri.

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