Telephonic Psychiatric Services (TiPS) - Practice Enrollment
General Information
Date
Practice Name
Main Address
Practice Type
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Adult
Family
FQHC
Pediatric
Pediatric/Family
School
SHBC
Other
Phone (back office)
Fax
Medical Director
Office Manager
Office Manager Email
Contact Person (if other than manager)
Behavioral Health on Site
Yes
No
If so, please include name here
Insurances
Aetna
Amerihealth
Gateway
Geisinger
Health Partners
Keystone
United
UPMC
Additional sites (please include phone number)
Site name
Phone
Agreement Section
We agree to participate in the TiPS project with the following regional team: Penn State Children's Hospital.
We agree to participate in training at the beginning of the project and continuing education as needed during the project.
We agree to continue to manage behavioral health care of appropriate cases for the primary care setting following case based education with the team.
We understand that the TiPS psychiatrist will not be prescribing medications.
Click to agree
Yes I agree
Tell us about your people
First name
Last name
Email
Title
Please select...
APRN
Care Coordinator
CFNP
CPNP
DO
FNP
LICSW
LMHC
LPN
MA
MD
NP
PA
PAC
PhD
PNP
Resident
RN
FTE
Type
Please select...
BH Clinician
BH Clinician/Case Manager
Care Coordinator
Case Manager
Child Psychiatrist
Family Medicine Resident
Family Physician
Internal Medicine Physician
Nurse Practitioner
Other RN/LPN
Pediatric Resident
Pediatrician
Physician Assistant
Psychiatric APRN
Other
Contact Information