TERM Applications
Instructions
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Form W-9 (Rev. December 2014)
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Request for Taxpayer Identification Number and Certification | 2017-11-02 |
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Instructions and FAQs Credentialing and Contracting (pdf)
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2020-02-19 | |
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TERM Panel Speciality Criteria (pdf)
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Revised 01/01/2021 | 2021-01-14 |
Credentialing Application
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1.1 Credentialing Criteria (pdf)
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2020-01-30 | |
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Credentialing Application Instructions (pdf)
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2020-02-26 |
TERM Therapist Applications
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TERM Therapist Clinical Application (docx)
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12/28/2020 | 2020-12-31 |
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Writing Sample Packet for Therapist (docx)
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2018-07-12 |
TERM Evaluator Applications
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TERM Evaluator Clinical Application (docx)
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12/28/2020 | 2020-12-31 |
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Writing Sample Packet for Evaluators (pdf)
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2018-07-10 |
Interns
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Evaluator Intern Packet (docx)
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2018-08-29 | |
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Therapy Intern Application (docx)
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2018-08-29 |
Specialty Addition Applications
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TERM Evaluator Provider: Specialty Addition Application (docx)
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Revised 02/27/2020 | 2020-02-27 |
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TERM Therapist Specialty Addition Application (pdf)
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Revised 05/26/20 | 2020-05-29 |