V: 0520
MEMBER MATCHING INFORMATION
This information will appear on your provider profile in the Optima Health Provider Directory. Please complete entirely; any
omitted information will be blank on the directory and may exclude you from a member's "Find a Provider" search
Provider Name: NPI: Tax ID:
1. Office Hours: These hours should be inclusive of your availability at all locations you may have with this practice tax ID.
2. Office Accessibility:
Wheelchair Accessible Public Transportation within one mile Use of TDD
3. Languages Spoken in the office:
English
Spanish
German
French
Vietnamese
Korean
Navajo
Tagalog
Portuguese
Italian
Arabic
Dakota
Yupik
Polish
French Creole
Other:
4. Gender and Ethnicity: (It is our experience that patients often express preferences for providers of a particular ethnic background or gender.
Providing this information will include you in the search list for these categories on our website.)
Gender: Ethnicity:
Male African-American Caucasian
Female American Indian/Alaska Native Hispanic
Asian Other:
5.
Cultural Competency Attestation
Has this provider completed Cultural Competency Training?
Yes No
6. Populations Seen (Behavioral Health only)
Younger Children (0-5 years) Women Gay / Lesbian Phillipine
Older Children (6-12 years) Family In-Patient Child/Adolescent Training/Fellowship
Adolescents (13-18 years) Couples Korean Child/Adolescent Board Certified MD
Adults Geriatric Hispanic
Men Step Families Vietnamese
7. Treatment Categories (Behavioral Health only, please check all that apply)
Addictions ECT-Outpatient Outpatient Treatment
ADHD Family/Victim Violence Phobias/Habit Disorders
Anger Management Forensic Evaluation Physically Impaired
Anxiety Disorders Grief Psychological Testing
Autism Spectrum Disorders Head Injury Patients PTSD
Bipolar Disorder Hearing Impaired Separation/Divorce
Blind/Visually Impaired HIV/AIDS Sexual Disorders
Christian Focus Hypnosis Sexual/Physical Abuse
Chronic Pain Inpatient Treatment Substance Abuse
Crisis Intervention Intellectually Disabled Terminally Ill
Depression Medication Management Therapy – Family
Development Disability Mood Disorders Therapy – Group
Eating Disorders Neuropsychological Testing Therapy – Individual
ECT-Inpatient Therapy - Marital/Couple