For Providers

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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:* 
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.*