Provider Registration Form

Register with CHAMP to gain access to our CE webinars and show your support for this program.

Primary Care Provider Name:*
Practice Name:*
Practice Address:*
City:*
Practice Phone Number:*	() -
Practice Email:*
Primary Care Provider Email:*
By enrolling in the CHAMP program: We agree to inform patients and/or guardians that we may engage the CHAMP program on their behalf and will share health information with the program unless the patient and/or guardian declines CHAMP services. We agree to, when possible, participate in CHAMP consultation, training, and educational opportunities. We agree to complete annual satisfaction surveys. We agree to continue to manage mental/ behavioral health care of cases appropriate for the primary care setting following consultations with the CHAMP team. We also agree to inform our patients and their caregivers that a telephone or telehealth consultation with CHAMP does not establish a provider/patient relationship between the patient and any member of the CHAMP team.
Typing your name here will be your signature acknowledging your agreement.*