Clinical psychologist (CP)

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Home ► Clinical psychologist (CP)

Last Modified: 4/10/2024 Location: FL, PR, USVI Business: Part A, Part B

Clinical psychologist (CP)

Qualification requirements

Clinical psychologists (CP) must meet all of the following criteria to provide services for Medicare beneficiaries:

• Doctorate in psychology

• Licensed or certified -- on the basis of the doctorate in psychology -- by the state in which he or she practices at the independent practice level of psychology to furnish diagnostic, assessment, preventive, and therapeutic services directly to individuals

Documentation requirements and recommendations

• Completed CMS-855I form external pdf file

Note: To expedite the processing of your provider enrollment application, you may use the internet-based PECOS external link

, which will automatically select the appropriate form and allow you to complete the application process online.

• Signed and dated certification statement -- all signatures must be original and signed in ink (blue ink preferred). Stamped, faxed, or copied signatures will not be accepted.

Note: If you submitted your application through internet-based PECOS, you may sign the application electronically or you must submit your paper certification statement within 15 days of your electronic submission.

• Completed Electronic Funds Transfer (EFT) Authorization Agreement (CMS-588) external pdf file

and associated documentation (e.g., copy of a voided check and/or a deposit slip). Please click here for more information.

Note: If a provider/supplier already receives payments electronically and is not making a change to his/her banking information, the CMS-588 is not required. In addition, physicians and non-physician practitioners who are reassigning their benefits to another entity are not required to submit the CMS-588.

• Include copies of the following supporting documents:

• A notarized copy or a certified “true copy” of the practitioner’s state medical license:

• A notarized copy must include the stamp that states “official seal” and the name of the notary public as well as the state, county, and date the notary’s commission expires.

• A certified “true copy” of an original document has a raised seal that identifies the state and county in which it originated or is stored.

Note: A provider/supplier located in Puerto Rico or U.S. Virgin Islands must include a copy of his or her Letter of Good Standing. The letters for Puerto Rico providers/suppliers will be considered valid if it was issued within 12 months of First Coast’s receipt of the enrollment application. The letters for U.S. Virgin Islands providers/suppliers will be considered valid if it was issued within six months of First Coast’s receipt of the enrollment application.

• Certificate of completion, transcript, and/or diploma from accredited educational program(s) required for certification and/or licensure (please refer to Qualification requirements section at the top of the page.)

Additional documentation requirements (when applicable)

Medicare may require additional documentation, when applicable, to validate key information contained within the enrollment application (e.g., name change, tax identification number, proof of citizenship) or to address specific issues that could adversely affect a practitioner’s potential eligibility for enrollment (e.g., adverse legal actions, financial relationships).

• Driver’s license

• Social Security card

• Marriage license

• U.S. passport

• NPI verification from National Plan and Provider Enumeration System (NPPES) -- only durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers are required to submit this type of documentation

• Written confirmation from the IRS verifying provider’s TIN is associated with the provider’s legal business name (e.g., IRS CP 575)

• Final adverse action documentation: Please include copies of legal documents associated with any final adverse action(s) taken against the provider as well as copies of any the legal documents showing its resolution (e.g., notifications, reinstatement letters).

Note: Documents containing a summary of the adverse actions taken or their resolution will not be accepted.

• Completed Medicare Participating Physician or Supplier Agreement (CMS-460) external pdf file

• Statement in writing from the practitioner’s bank (or other financial institution) -- if Medicare payments will be sent to a practitioner’s bank with which he or she has a lending relationship (i.e., any type of loan), then the practitioner must provide a statement in writing from the bank -- which must be specified in the loan agreement -- that the lender has agreed to waive its right of offset for Medicare receivables.

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