This form is for Colorado licensed behavioral health services providers to apply for reimbursement through the any of TCHN’s therapy scholarship funds. To be added to the Approved Providers List please submit a current Colorado license, a completed direct deposit form and W9 form below. Tri-County Health Network will process the application and determine eligibility within 10 working days. Services provided prior to approval will not be reimbursed by our funds. If you have any questions, please contact Tri-County Health Network at BHFUND@tchnetwork.org.

Provider Information

Provider Name*

Are you a Colorado licensed Social Worker, Marriage and Family Therapist, Psychologist, or Professional Counselor?*YesNo

STOP. Do not submit this application. You must be a Colorado licensed provider to be eligible for reimbursement through the San Miguel Behavioral Health Fund. If you have questions, please contact Tri-County Health Network at BHFUND@tchnetworkstg.wpenginepowered.com .

Colorado License Number*

EIN Number*

Business Name (if applicable)

Email Address*

Phone Number*

Billing Address*

City*

State*

Zip*

Documentation Requirements

Providers are required to submit an updated W-9, a completed direct deposit form, and a current copy of their Colorado license before reimbursement can be paid.

If you have problems uploading your documents via this form, you can email them to BHFUND@tchnetworkstg.wpenginepowered.com instead.

Please upload a copy of your W-9 here.
*** File must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 2MB ***

Please complete and upload both direct deposit forms. Payments for SMBHF clients come from San Miguel County, while payments for RAF and the YF come from TCHN.

Download the TCHN direct deposit form here.
*** File must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 2MB ***

Download the direct deposit form for SMC here.
*** File must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 2MB ***

Please upload a copy of your current Colorado license here.
*** File must be either jpg, jpeg, png, gif, pdf, doc, or docx with a maximum file size of 2MB ***

Electronic Signature Agreement

I certify, to the best of my knowledge, that all information in this application is true and accurate. I understand that all information is subject to verification and approval by Tri-County Health Network.

The parties agree that this agreement may be electronically signed. The parties acknowledge that electronic signatures appearing on this agreement are the same as handwritten signatures for the purposes of validity, enforceability and admissibility.

Signature*

(Use your mouse or trackpad to sign.)

Printed Name*

Today's Date*