**PLEASE BE SURE to use the email that is listed as your primary email with Grow Therapy. Failure to do so, could result in you not being credentialed in an additional state.
Please note: If you are an NP or PMHNP, you may only apply to work with Grow Therapy in one additional state per form submission. If you have more than one state to add, please submit a new form for each additional state.
Grow Therapy requires all Nurse Practitioners to maintain an active Collaborating Agreement with a physician for each state they practice, unless state regulations permit Full Practice Authority.
If you have questions about state Collaborating Physician requirements, how to obtain autonomy, or to see if you qualify for independent practice, see our Guide for Collaborative Agreement Requirements at Grow.
Since you do not have an active Collaborative Agreement or Proof of Autonomy, you cannot proceed. Please complete a new form once your documentation is ready.
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Grow Therapy requires all providers to meet and maintain the minimum criteria for participation.
Valid, current licensure that grants the practitioner authority to diagnose clients as applicable to where practitioners are providing care.
Valid, current Drug Enforcement Agency (DEA) certificate in the state where seeing patients (MDs, DOs, and NPs only).
Completion of appropriate training for the specialty practiced such as residency program approved by state and accreditation bodies.
No current sanctions or limitations on licensure.
Must not appear on any Federal or State Sanctions or Exclusions as outlined in the “Primary Source Verification Process” Section of Grow's Credentialing Policies & Procedures.
Malpractice Coverage Amounts will meet state limits based on the provider type. If state limits are not specified, amounts will meet $1 million/$3 million. No shared limits will be accepted.
No unprofessional conduct as reported to the NPDB or state medical board that may have or has the potential to impact patient care. The Committee reserves the right to review any reports of unprofessional conduct and determine whether it will disqualify the applicant.
Practitioners must not have unsatisfactory liability claims history including but not limited to lawsuits, arbitration, mediation, settlements or judgements. An unsatisfactory liability claims history may include but not be limited to, multiple claims related to the same or similar service, settlements of $100,000 for non-prescribing practitioners and $250,000 for prescribing practitioners for any single case in the past 10 years.
No liability claims, judgments, or settlements for sexual misconduct, at any time during professional career.
Practitioners must not have any current licensure probation, reduction or restriction of duties or privileges, or any such liability claims, cases or actions pending, by which in the view of the Committee would raise concerns about the future professional performance, conduct and competency of care.
These criteria are based on the NCQA standards and requirements from the payors with which Grow partners. Please view Grow's Credentialing Policies & Procedures for more information.
If you do not meet the minimum criteria at this time and are unable to accurately attest above, please DO NOT continue to fill out this form, and reach out to your Provider Growth Associate for guidance.
IMPORTANT! Federal DEAs are not accepted. If you do not have a current DEA number in that state, please make sure it is not selected below.
I, {legalName}, attest that the information provided in this declaration is true and accurate.
In the event that I do not currently hold a DEA registration in a specific state where I intend to practice, I acknowledge and agree to the following:
Prescribing Limitations: I understand that I am not authorized to prescribe controlled substances in any state where I do not hold an active license and DEA registration, and I will not prescribe in those states.
Compliance with State and Federal Requirements: I will adhere to all state and federal requirements regarding the prescribing of controlled substances and understand that any violation of these requirements will result in immediate termination of my contractual agreement with Grow Therapy.
Notification of Status: I will notify Grow Therapy immediately upon obtaining a DEA registration in a pending state and will await approval for credentialing prior to prescribing controlled substances in any newly acquired DEA state. Additionally, should I choose to let any existing DEA registrations lapse, I will immediately notify Grow Therapy of this decision.
Declaration of Current Status:
I attest that my current DEA registration status in the state(s) where I intend to practice are indicated above, and that I have no additional DEA registrations and will not prescribe controlled substances in other states.
Some providers may have existing Non-Compete Agreements or legal Conflicts of Interest and cannot be credentialed with certain insurances...
Please let us know which insurance(s) you are unable to be credentialed with below.
Please note: Grow does not currently allow providers to bill directly with Medicare or Medicaid. Instead, we work with Managed Care plans, which require separate enrollment processes from the state. If you choose to enroll with and see Medicare or Medicaid clients below, we will automatically enroll you with the Managed Care plans available in your licensed state(s).
TX Medicaid EnrollmentWe understand that these questions can be personal, so we want to highlight that Grow Therapy does not require this information. These are required questions on the Texas Medicaid enrollment application. If you decide not to answer any of the questions, we unfortunately will not be unable to submit a Texas Medicaid application on your behalf.
In order to submit your application to enroll with Medi-Cal as a provider, our enrollment team must create an account for you on PAVE, Medi-Cal’s provider portal.
Once the account is created, they will add Mary Riggs, Grow Therapy’s authorized official with Medi-Cal, as an authorized official on your account. This will allow the team to create your Medi-Cal application, E-sign it, and submit it on your behalf.
Once your application is submitted, we will send to you the login information we’ve used and prompt you to login on PAVE and change your username and password.
However, if we find that you have an Existing PAVE portal account you will be prompted by email to E-sign the application after we create your application.
Authorization
If you do not wish to grant Grow Therapy authorization please note that we will NOT be able to credential you with Medi-Cal.
"Title XX is the Block Grants and Programs for Social Services and Elder Justice. These programs support a wide range of social policy goals, including preventing child abuse, increasing availability of child care, and providing community-based care for the elderly and disabled. They promote social services and seek to decrease elder abuse, neglect, and exploitation."
Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider's total operating expenses.
Subcontractor means—(a) An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or(b) An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement.
Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds, or a pharmaceutical firm).
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