Provider Profile

Instructions

Please complete the form below. Once you've completed the form, click the Submit Your Profile button at the bottom of the page.

IMPORTANT : You will NOT be able to save and come back later to finish, so please make sure you have all of the necessary information before getting started.

Back to Getting Started Page

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+ Information appears in online listing that is accessible to NC social workers (requires log-in). NOTE: Listing of your information in the portal is subject to CMEP review and to maintaining adequate continuing education credits.



Your Profile

Tell us about you, and how best to contact you.

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* Your email will be your account username
(for NC social workers only)
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Your Practice

Tell us about your practice, including an administrative contact if available.

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(medical only)

Continuing Education Details

Please provide information about your continuing education over the past 24 months. If your credits cover more than one Education Type, please choose the Education Type and Date Completed that represents the majority of your credits and indicate the other education types (with dates) in the Description field.

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Help Us Complete Your Request

By uploading a current W-9 Form for your practice, a current CV, and a signed CMEP Agreement Letter, you can help speed up our review of your profile. Simply click the links below to upload PDFs or scanned images of the requested documents. If you don't have these forms, you can submit your profile anyway.


Upload Completed Form W-9


Upload Current CV


Upload Signed Agreement Letter


Where You Provide Services

Let us know where you provide your services. All information will appear on the online provider listing.+


Let us know the address at which you provide services. If you provide services at multiple locations, enter information for your primary service location below and contact us afterwards to provide other service locations. Contact instructions are at the bottom of this form (submit the form first!).

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Your Billing Details

Let us know where to send reimbursement checks for completed evaluations (reimbursement subject to CMEP review and approval of services provided).



If reimbursements to your practice are handled by a third-party Account Receivables (A/R) vendor, please tell us the name of that vendor below:



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All done? Please click the button below to submit your profile to CMEP for review. For status or follow-up questions, please contact CMEP from their main web site using the CMEP Home link at the top of this page.