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Prince George's County, Maryland, USA

Behavioral Health Services New Provider

Please complete the information below for your program.  The information on this form is used to update our referral lists.  The information is provided to consumers and professionals seeking behavioral health resources.
Do you offer services in another county?
If so, which county?

Please enter office hours with the following format: 9 am - 5 pm

Monday Tuesday Wednesday Thursday Friday Weight
Website
Phone Number
Is your agency associated with an opioid medication provider?
If yes, what method of treatment?
Select all that apply.
Do you have a PT50 DATA 2000 Waived Practitioner?
Is your agency registered with Maryland Medicaid as a distant site provider eligible to perform services via telehealth?
Do you offer services

Select all that apply.
Who do you serve?

Select all that apply.
What types of insurance(s) does your program accept?

Select all of the types of payment methods accepted.
Languages Available for Services

Select all that apply.
Accrediting Body
Have you received a COMAR 10.63 License?
Outpatient Services Provided

Select all services provided by your program.
Residential Services Provided

Select all services provided by your program.
Specialty Services Provided

Select All Specialty Services Offered.

Use this space to list services offered in a different language and any additional information about your services.

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