Provider Service Availability and Agreement

Do you or your company have a PUBLISHED Resource Guide Listing? *

Yes. Please proceed.
No. A published RG listing is required

Please ensure your Resource Guide listing is published. An individual practice subscription is $12.95 per month per provider (1-5 providers). A corporate subscription is $99 per month for practices with 5 providers or greater. Indicate your company / organization name on this agreement. Non-Profits are free with verified documentation.

Please select your Business Name from the List Below

If you do not see your business in the list, please contact BLHFguide@borislhensonfoundation.org to make sure your Resource Guide listing is published.

Please review and acknowledge acceptances of all criteria by checking the associated box. *

I certify that I have (1) attended a live Provider Onboarding Training OR (2) watched a Provider Onboarding Training Video.
I agree with the timeliness and communication expectations as an independent, licensed mental health provider collaborating with the BLHF organization addressed in the Provider Onboarding Training.
I understand and will support client survey reminders to receive compensation for completed sessions. The client should be encouraged to complete a Quality-of-Care Survey AFTER EACH session.
I agree to submit an invoice per client for services completed within two (2) weeks of the session and no later than October 30th for all clients participating in the Mental Wellness Support Program. Invoice can only be submitted for completed session over 45 minutes and does not include office orientation, brief intakes or no-show fees.
I agree that I must contact the organization if my availability changes.
I have the state mandated liability and malpractice insurance (as mandated by the state in which I practice) and I, for myself and on behalf of any practice, company, organization or entity to which I may be a part and each and any employee, officer, partner, member, staff, personnel, and/or affiliated or related individual or entity thereof, shall indemnify, defend, irrevocably release, discharge, absolve, covenant not to sue and hold the Boris Lawrence Henson Foundation (“BLHF”) (and any other relation to the organization whether individual or entity) and each and any employee, partner, member, staff, personnel and/or affiliated or related individual or entity harmless against any and all claims, liabilities and causes of action (whether third party or otherwise) of whatsoever nature arising from misrepresentation, default, misconduct, failure to perform or any other act related to this agreement and/or service provided as a part of this agreement.
I understand the relationship between myself, my company and BLHF shall at all times be that of independent contractors. No employment, partnership or joint venture relationship is formed by this referral agreement and at no time may I position myself as affiliated to BLHF, except as an independent referrer. In view of this independent relationship, I shall not enter into any agreements on behalf of the BLHF, shall make no guarantees either expressed or implied on behalf of BLHF.

Documentation Reviewed and Approved for Campaign

The 2021 MWSP Provider Orientation webinar offers an overview of participant, provider and service eligibility, provider agreement, access guidelines, and the invoice process. The intended audience are licensed clinicians and their administrative or office management teams.

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New Resource Guide Members

Provider Service Availability and Agreement

The 2021 MWSP Provider Orientation webinar offers an overview of participant, provider and service eligibility, provider agreement, access guidelines, and the invoice process. The intended audience are licensed clinicians and their administrative or office management teams.

Return to Home Page

Recent Posts

*New* Resource Guide Members

New Resource Guide Members