AllOne Health

REQUEST TO JOIN OUR AFFILIATE NETWORK

Practice Type*
- Group (Your practice employs multiple counseling staff)
- Individual (Your practice does not employ multiple counseling staff)
Business Name (Must Match W-9)*
Primary Contact*
First Last
Email Address*
Phone Number*
Fax Number
Primary Office Address*
Street Address City State ZIP / Postal Code Country
Availability
What are your normal business hours?
What are your evening hours?
What are your weekend hours?
Billing Address*
Street Address City State ZIP / Postal Code Country
Sign up for Direct Deposit*
- Yes
- No
Liability Insurance Coverage Policy meets criteria 1MIL- 3MIL*
- Yes
- No
License is in good standing with state board*
- Yes
- No
Insurance Plans Accepted - Please select all that apply.
- Aetna
- Beacon Health Options
- Blue Cross Blue Shield
- Cigna
- ComPsych
- Great West
- Humana
- Kaiser
- Magellan
- Managed Health Network
- Medica
- Medicaid
- Medical Assistance
- Medicare
- MHNet
- Multiplan
- Optum
- Pacificare
- TriCare
- United Behavioral Health
- United Health Group
- United Healthcare
- ValueOptions
- None
Upload W-9, License(s), Liability Insurance facesheet, additional office location(s) and any other supportive documentation. (Please select one file at a time.)*
Drop files here or

Max. file size: 512 MB.