EMDR EBP Provider Application

I. Agency Service Data

Agency Name(Required)

Primary County of Service(Required)

Primary Address Medicaid Enrollment ID

Primary Agency Address(Required)

Street Address Address Line 2 City State ZIP Code

Is this EBP delivered in a secondary location other than the address provided above?(Required)

Yes

No

Second County of Service(Required)

Second Address Medicaid Enrollment ID

Second Address where EBP is delivered(Required)

Street Address Address Line 2 City State ZIP Code

Is this EBP delivered in another location other than the address provided above?(Required)

Yes

No

Third County of Service(Required)

Third Address Medicaid Enrollment ID

Third Address EBP is delivered(Required)

Street Address Address Line 2 City State ZIP Code

Is this EBP delivered in another location other than the address provided above?(Required)

Yes

No

Fourth County of Service(Required)

Fourth Address Medicaid Enrollment ID

Fourth Address EBP is delivered(Required)

Street Address Address Line 2 City State ZIP Code

Which populations does the EMDR team serve?(Required)

Check all that apply

Children

Adolescents

Adults

Does your agency currently work with/accept referrals for children in state custody (child welfare)?(Required)

Yes

No

Level of care or service where EMDR is delivered(Required)

Please describe level of care or service where EMDR is delivered(Required)

Agency is current funded by/contracted with the following:(Required)

Select all that apply.

MCO- Blue Cross Blue Shield of New Mexico (Centennial Care)

MCO-Presbyterian Health Plan (Centennial Care)

MCO-Western Sky Community Care (Centennial Care)

NM Medicaid Fee for Service

Direct Contract with CYFD

Direct Contract with BHSD

Other

Other funding/contract(Required)

Point of Contact Name(Required)

Application status update and approval information will be sent to this individual.

First Last

Title(Required)

Email(Required)

Phone(Required)

Any additional or clarifying information about current EMDR services your agency provides

You will provide practitioner name and qualification information on the following page.

II. Staff Roster and Qualification

List each qualified staff member at the agency.

Name of Practitioner #1(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Select highest level of EMDR International Association (EMDRIA) training received(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

EMDRIA Certification Program

EMDRIA Approved Basic Training

Upload certificate of completion of EMDRIA Certification Program or EMDRIA Approved Basic Training(Required)

Upload EMDR International Association (EMDRIA) Certification Program certificate or EMDRIA Approved Basic Training certificate of completion.

Continuing Education certificates WILL NOT be accepted.

Drop files here or

Max. file size: 100 MB.

Documentation must demonstrate that the training was provided by an EMDRIA Approved EMDR Training Provider (emdria.org)

Name of Trainer(s)(Required)

Provide Link of Trainer's Qualifications(Required)

Provide Trainer's link on EMDRIA find a provider list* or provider's website.

*Profile must list EMDR Trainer to be approved trainer

Additional Practitioners in this EBP?(Required)

Yes

No

Name of Practitioner #2(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Select highest level of EMDR International Association (EMDRIA) training received(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

EMDRIA Certification Program

EMDRIA Approved Basic Training

Upload certificate of completion of EMDRIA Certification Program or EMDRIA Approved Basic Training(Required)

Upload EMDR International Association (EMDRIA) Certification Program certificate or EMDRIA Approved Basic Training certificate of completion.

Continuing Education certificates WILL NOT be accepted.

Drop files here or

Max. file size: 100 MB.

Documentation must demonstrate that the training was provided by an EMDRIA Approved EMDR Training Provider (emdria.org)

Name of Trainer(s)(Required)

Provide Link of Trainer's Qualifications(Required)

Provide Trainer's link on EMDRIA find a provider list* or provider's website.

*Profile must list EMDR Trainer to be approved trainer

Additional Practitioners in this EBP?(Required)

Yes

No

Name of Practitioner #3(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Select highest level of EMDR International Association (EMDRIA) training received(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

EMDRIA Certification Program

EMDRIA Approved Basic Training

Upload certificate of completion of EMDRIA Certification Program or EMDRIA Approved Basic Training(Required)

Upload EMDR International Association (EMDRIA) Certification Program certificate or EMDRIA Approved Basic Training certificate of completion.

Continuing Education certificates WILL NOT be accepted.

Drop files here or

Max. file size: 100 MB.

Documentation must demonstrate that the training was provided by an EMDRIA Approved EMDR Training Provider (emdria.org)

Name of Trainer(s)(Required)

Provide Link of Trainer's Qualifications(Required)

Provide Trainer's link on EMDRIA find a provider list* or provider's website.

*Profile must list EMDR Trainer to be approved trainer

Additional Practitioners in this EBP?(Required)

Yes

No

Name of Practitioner #4(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Select highest level of EMDR International Association (EMDRIA) training received(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

EMDRIA Certification Program

EMDRIA Approved Basic Training

Upload certificate of completion of EMDRIA Certification Program or EMDRIA Approved Basic Training(Required)

Upload EMDR International Association (EMDRIA) Certification Program certificate or EMDRIA Approved Basic Training certificate of completion.

Continuing Education certificates WILL NOT be accepted.

Drop files here or

Max. file size: 100 MB.

Documentation must demonstrate that the training was provided by an EMDRIA Approved EMDR Training Provider (emdria.org)

Name of Trainer(s)(Required)

Provide Link of Trainer's Qualifications(Required)

Provide Trainer's link on EMDRIA find a provider list* or provider's website.

*Profile must list EMDR Trainer to be approved trainer

Additional Practitioners in this EBP?(Required)

Yes

No

Name of Practitioner #5(Required)

First Last

Title(Required)

Email(Required)

Phone(Required)

Degree(Required)

Licensure(Required)

Licensure Number(Required)

Employment status(Required)

Staff

Contractor

Independent Practitioner

Practitioner NPI(Required)

Select highest level of EMDR International Association (EMDRIA) training received(Required)

Visit EMDRIA to learn more about certification or https://www.emdria.org/training-faqs/ to learn more about EMDRIA Approved Basic Training.

EMDRIA Certification Program

EMDRIA Approved Basic Training

Upload certificate of completion of EMDRIA Certification Program or EMDRIA Approved Basic Training(Required)

Upload EMDR International Association (EMDRIA) Certification Program certificate or EMDRIA Approved Basic Training certificate of completion.

Continuing Education certificates WILL NOT be accepted.

Drop files here or

Max. file size: 100 MB.

Documentation must demonstrate that the training was provided by an EMDRIA Approved EMDR Training Provider (emdria.org)

Name of Trainer(s)(Required)

Provide Link of Trainer's Qualifications(Required)

Provide Trainer's link on EMDRIA find a provider list* or provider's website.

*Profile must list EMDR Trainer to be approved trainer

Additional Practitioners in this EBP?(Required)

Yes

No

The limit for the number of practitioners per application has been met.

Please email [email protected] if EMDR team is greater than five.

I. Agency Service Data

II. Staff Roster and Qualification

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