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Required format:

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/^(((\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00))([-\/])02(\6)29)|(\d{4}([-\/])((0[1-9]|1[012])(\9)(0[1-9]|1\d|2[0-8])|((0[13-9]|1[012])(\9)(29|30))|((0[13578]|1[02])(\9)31)))) (\d|[0-1]\d|[2][0-3]):[0-5]\d$/

/^((29([-\/])02\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1\d|2[0-8])([-\/])(0[1-9]|1[012]))|((29|30)([-\/])(0[13-9]|1[012]))|(31([-\/])(0[13578]|1[02])))(\11|\15|\18)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/

/^((02([-\/])29\3(\d{2}([13579][26]|[2468][048]|04|08)|(1600|2[048]00)))|((((0[1-9]|1[012])([-\/])(0[1-9]|1\d|2[0-8]))|((0[13-9]|1[012])([-\/])(29|30))|((0[13578]|1[02])([-\/])31))(\11|\15|\19)\d{4})) (\d|[0-1]\d|[2][0-3])(:[0-5]\d){2}$/

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Provider Gambling Services Referral Sign Up Form

The Maryland Department of Health, Behavioral Health Administration (BHA) will reimburse providers for the treatment of problem gambling through Optum as of January 1, 2020. BHA is in the process of developing a referral list of eligible providers who are willing to provide gambling services.

If you are an eligible provider that is enrolled with Medicaid, are willing to provide gambling services, and would like to be on the gambling services referral list, please complete the information below that will be submitted to the Center of Excellence for Problem Gambling. Once reviewed for accuracy, your program will be added to the referral list of providers for gambling services.

Please note: If your organization/agency has more then one office/location, please submit a separate sign up form for each location.

Loading...

Record Date

M-D-Y

[HIDDEN]1. Filling out for a:

Practitioner

Treatment Program

1a. Filling out for a:

Private Practitioner

Provider

[HIDDEN]2. Choose which applies:

New sign up

Information change

3. Name of provider (program or individual practitioner):

3a. Agency contact person--individual a help seeker can contact when calling the agency

3a1. Contact Person First Name:

3a2. Contact Person Last Name:

4. Phone number

5. Address:

6. City/Town:

[HIDDEN]7. State:

7a. State:

8. Zip/Postal code:

9. County:

10. E-mail address:

Website URL:

11. Enrolled with Medicaid:

Yes

No

[HIDDEN]11a. Enrolled with Medicaid and the problem gambling reimbursement program:

Yes

No

12. Would you be interested in clinical training?

Yes

No

Please complete the section below. This information will be listed in the referral directory for Help seekers to contact you for appointment and treatment

All locations needs to be in the state of Maryland

20. How many locations are you listing?

Location 1 information:

______
______
______
______
______
______
______

Contact First Name for appointment

Contact Last Name for appointment

19. Phone Number to call for appointment

Address

City/Town

State

Zip/Postal Code

County

13. Please indicate the days, then hours of operation:

13a. Monday

Open

Closed

Hours of operation

Yes

No

13a1. Standard hours

13a2. By appointment only

13a3. Other arrangements

13a1a. Monday standard opening

H:M

13a1b. Monday standard closing

H:M

13a3a. Please specify other arrangements:

13b. Tuesday

Open

Closed

Hours of operation

Yes

No

13b1. Standard hours

13b2. By appointment only

13b3. Other arrangements

13b1a. Tuesday standard opening

H:M

13b1b. Tuesday standard closing

H:M

13b3a. Please specify other arrangements:

13c. Wednesday

Open

Closed

Hours of operation

Yes

No

13c1. Standard hours

13c2. By appointment only

13c3. Other arrangements

13c1a. Wednesday standard opening

H:M

13c1b. Wednesday standard closing

H:M

13c3a. Please specify other arrangements:

13d. Thursday

Open

Closed

Hours of operation

Yes

No

13d1. Standard hours

13d2. By appointment only

13d3. Other arrangements

13d1a. Thursday standard opening

H:M

13d1b. Thursday standard closing

H:M

13d3a. Please specify other arrangements:

13e. Friday

Open

Closed

Hours of operation

Yes

No

13e1. Standard hours

13e2. By appointment only

13e3. Other arrangements

13e1a. Friday standard opening

H:M

13e1b. Friday standard closing

H:M

13e3a. Please specify other arrangements:

13f. Saturday

Open

Closed

Hours of operation

Yes

No

13f1. Standard hours

13f2. By appointment only

13f3. Other arrangements

13f1a. Saturday standard opening

H:M

13f1b. Saturday standard closing

H:M

13f3a. Please specify other arrangements:

13g. Sunday

Open

Closed

Hours of operation

Yes

No

13g1. Standard hours

13g2. By appointment only

13g3. Other arrangements

13g1a. Sunday standard opening

H:M

13g1b. Sunday standard closing

H:M

13g3a. Please specify other arrangements:

14. Please specify services provided for Gambling Disorder

Yes

No

14a. Individual counseling

14b. Family counseling

14c. Group counseling

14d. Couples counseling

14e. Teen/adolescents counseling

14f. Other

14f1. Specify other:

15. Please specify documents required for first appointment

Yes

No

15a. Photo id

15b. Identification card

15c. Other

15c1. Specify other:

16. Please specify if you provide support for persons with special requirements

Yes

No

16a. Wheelchair access

16b. Language services other than English

16c. Hearing and visually impaired services

16d. Other

16d1. Specify other:

Location 2 information:

21. Contact Person First Name for appointment:

22. Contact Person Last Name for appointment:

23. Phone number to call for appointment:

24. Address:

25. City/Town:

26. State

27. Zip/Postal code:

28. County:

29. Email address:

30. Alternative Phone Number

31. Please indicate the days, then hours of operation:

31a. Monday

Open

Closed

Hours of operation

Yes

No

31a1. Standard hours

31a2. By appointment only

31a3. Other arrangements

31a1a. Monday standard opening

H:M

31a1b. Monday standard closing

H:M

31a3a. Please specify other arrangements:

31b. Tuesday

Open

Closed

Hour of operation

Yes

No

31b1. Standard hours

31b2. By appointment only

31b3. Other arrangements

31b1a. Tuesday standard opening

H:M

31b1b. Tuesday standard closing

H:M

31b3a. Please specify other arrangements:

31c. Wednesday

Open

Closed

Hours of operation

Yes

No

31c1. Standard hours

31c2. By appointment only

31c3. Other arrangements

31c1a. Wednesday standard opening

H:M

31c1b. Wednesday standard closing

H:M

31c3a. Please specify other arrangements:

31d. Thursday

Open

Closed

Hours of operation

Yes

No

31d1. Standard hours

31d2. By appointment only

31d3. Other arrangements

31d1a. Thursday standard opening

H:M

31d1b. Thursday standard closing

H:M

31d3a. Please specify other arrangements

31e. Friday

Open

Closed

Hours of operation

Yes

No

31e1. Standard hours

31e1. By appointment only

31e3. Other arrangements

31e1a. Friday standard opening

H:M

31e1b. Friday standard closing

H:M

31e3a. Please specify other arrangements:

31f. Saturday

Open

Closed

Hours of operation

Yes

No

31f1. Standard hours

31f2. By appointment only

31f3. Other arrangements

31f1a. Saturday standard opening

H:M

31f1b. Saturday standard closing

H:M

31f3a. Please specify other arrangements

31g. Sunday

Open

Closed

Hours of operation

Yes

No

31g1. Standard hours

31g2. By appointment only

31g3. Other arrangements

31g1a. Sunday standard opening

H:M

31g1b. Sunday standard closing

H:M

31g3a. Please specify other arrangements

32. Please specify services provided for Gambling Disorder

Yes

No

32a. Individual counseling

32b. Family counseling

32c. Group counseling

32d. Couples counseling

32e. Teen/adolescents counseling

32f. Other

32f1. Specify other

33. Please specify documents required for first appointment

Yes

No

33a. Photo id

33b. Identification card

33c. Other

33c1. Specify other:

34. Please specify if you provide support for persons with special requirements

Yes

No

34a. Wheelchair access

34b. Language services other than English

34c. Hearing and visually impaired services

34d. Other

34d1. Specify other:

Location 3 information:

35. Contact Person First Name for appointment:

36. Contact Person Last Name for appointment:

37. Phone number to call for appointment :

38. Address:

39. City/Town:

40. State:

41. Zip/Postal code:

42. County:

43. Email address:

44. Alternative Phone Number:

45. Please indicate the days, then hours of operation:

45a. Monday

Open

Closed

Hours of operation

Yes

No

45a1. Standard hours

45a2. By appointment only

45a3. Other arrangements

45a1a. Monday standard opening:

H:M

45a1b. Monday standard closing:

H:M

45a3a. Please specify other arrangementsL

45b. Tuesday

Open

Closed

Hours of operation

Yes

No

45b1. Standard hours

45b2. By appointment only

45b3. Other arrangements

45b1a. Tuesday standard opening

H:M

45b1b. Tuesday standard closing

H:M

45b3a. Please specify other arrangement

45c. Wednesday

Open

Closed

Hours of operation

Yes

No

45c1. Standard hours

45c2. By appointment only

45c3. Other arrangements

45c1a. Wednesday standard opening

H:M

45c1b. Wednesday standard closing

H:M

45c3a. Please specify other arrangements:

45d. Thursday

Open

Closed

Hours of operation

Yes

No

45d1. Standard hours

45d2. By appointment only

45d3. Other arrangements

45d1a. Thursday standard opening

H:M

45d1b. Thursday standard closing

H:M

45d3a. Please specify other arrangements

45e. Friday

Open

Closed

Hours of operation

Yes

No

45e1. Standard hours

45e2. By appointment only

45e3. Other arrangements

45e1a. Friday standard opening

H:M

45e1b. Friday standard closing

H:M

45e3a. Please specify other arrangements

45f. Saturday

Open

Closed

Hours of operation

Yes

No

45f1. Standard hours

45f2. By appointment only

45f3. Other arrangements

45f1a. Saturday standard opening

H:M

45f1b. Saturday standard closing

H:M

45f3a. Please specify other arrangements

45g. Sunday

Open

Closed

Hours of operation

Yes

No

45g1. Standard hours

45g2. By appointment only

45g3. Other arrangements

45g1a. Sunday standard opening

H:M

45g1b. Sunday standard closing

H:M

45g3a. Please specify other arrangements

46. Please specify services provided for Gambling Disorder

Yes

No

46a. Individual counseling

46b. Family counseling

46c. Group counseling

46d. Couples counseling

46e. Teen/adolescents counseling

46f. Other

46f1. Specify other

47. Please specify documents required for first appointment

Yes

No

47a. Photo id

47b. Identification card

47c. Other

47c1. Specify other

48. Please specify if you provide support for persons with special requirements

Yes

No

48a. Wheelchair access

48b. Language services other than English

48c. Hearing and visually impaired services

48d. Other

48d1. Specify other:

Location 4 information:

49. Contact person First Name for appointment :

50. Contact person Last Name for appointment:

51. Phone number to call for appointment:

52. Address:

53. City/Town:

54. State:

55. Zip/Postal code:

56. County:

57. Email address:

58. Alternative Phone Number:

59. Please indicate the days, then hours of operation:

59a. Monday

Open

Closed

Hours of operation

Yes

No

59a1. Standard hours

59a2. By appointment only

59a3. Other arrangements

59a1a. Monday standard opening

H:M

59a1b. Monday standard closing

H:M

59a3a. Please specify other arrangements:

59b. Tuesday

Open

Closed

Hours of operation

Yes

No

59b1. Standard hours

59b2. By appointment only

59b3. Other arrangements

59b1a. Tuesday standard opening

H:M

59b1b. Tuesday standard closing

H:M

59b3a. Please specify other arrangements:

59c. Wednesday

Open

Closed

Hours of operation

Yes

No

59c1. Standard hours

59c2. By appointment only

59c3. Other arrangements

59c1a. Wednesday standard opening

H:M

59c1b. Wednesday standard closing

H:M

59c3a. Please specify other arrangements:

59d. Thursday

Open

Closed

Hours of operation

Yes

No

59d1. Standard hours

59d2. By appointment only

59d3. Other arrangements

59d1a. Thursday standard opening

H:M

59d1b. Thursday standard closing

H:M

59d3a. Please specify other arrangements:

59e. Friday

Open

Closed

Hours of operation

Yes

No

59e1. Standard hours

59e2. By appointment only

59e3. Other arrangements

59e1a. Friday standard opening

H:M

59e1a. Friday standard closing

H:M

59e3a. Please specify other arrangements:

59f. Saturday

Open

Closed

Hours of operation

Yes

No

59f1. Standard hours

59f2. By appointment only

59f3. Other arrangements

59f1a. Saturday standard opening

H:M

59f1b. Saturday standard closing

H:M

59f3a. Please specify other arrangements:

59g. Sunday

Open

Closed

Hours of operation

Yes

No

59g1. Standard hours

59g2. By appointment only

59g3. Other arrangements

59g1a. Sunday standard opening

H:M

59g1b. Sunday standard closing

H:M

59g3a. Please specify other arrangements:

60. Please specify services provided for Gambling Disorder

Yes

No

60a. Individual counseling

60b. Family counseling

60c. Group counseling

60d. Couples counseling

60e. Teen/adolescents counseling

60f. Other

60f1. Specify other:

61. Please specify documents required for first appointment

Yes

No

61a. Photo id

61b. Identification card

61c. Other

61c1. Specify other:

62. Please specify if you provide support for persons with special requirements

Yes

No

62a. Wheelchair access

62b. Language services other than English

62c. Hearing and visually impaired services

62d. Other

62d1. Specify other:

Location 5 information:

63. Contact Person First Name for appointment:

64. Contact Person Last Name for appointment :

65. Phone number to call for appointment:

66. Address:

67. City/Town:

68. State:

69. Zip/Postal code:

70. County

71. Email address:

Alternative Phone Number:

72. Please indicate the days, then hours of operation::

72a. Monday

Open

Closed

Hours of operation

Yes

No

72a1. Standard hours

72a2. By appointment only

72a3. Other arrangements

72a1a. Monday standard opening

H:M

72a1b. Monday standard opening

H:M

72a3a. Please specify other arrangements:

72b. Tuesday

Open

Closed

Hours of operation

Yes

No

72b1. Standard hours

72b2. By appointment only

72b3. Other arrangements

72b1a. Tuesday standard opening

H:M

72b1b. Tuesday standard closing

H:M

72b3a. Please specify other arrangements:

72c. Wednesday

Open

Closed

Hours of operation

Yes

No

72c1. Standard hours

72c2. By appointment only

72c3. Other arrangements

72c1a. Wednesday standard opening

H:M

72c1b. Wednesday standard closing

H:M

72c3a. Please specify other arrangements:

72d. Thursday

Open

Closed

Hours of operation

Yes

No

72d1. Standard hours

72d2. By appointment only

72d3. Other arrangements

72d1a. Thursday standard opening

H:M

72d1b. Thursday standard closing

H:M

72d3a. Please specify other arrangements:

72e. Friday

Open

Closed

Hours of operation

Yes

No

72e1. Standard hours

72e2. By appointment only

72e3. Other arrangements

72e1a. Friday standard opening

H:M

72e1b. Friday standard closing

H:M

72e3a. Please specify other arrangements:

72f. Saturday

Open

Closed

Hours of operation

Yes

No

72f1. Standard hours

72f2. By appointment only

72f3. Other arrangements

72f1a. Saturday standard opening

H:M

72f1b. Saturday standard closing

H:M

72f3a. Please specify other arrangements:

72g. Sunday

Open

Closed

Hours of operation

Yes

No

72g1. Standard hours

72g2. By appointment only

72g3. Other arrangements

72g1a. Sunday standard opening

H:M

72g1b. Sunday standard closing

H:M

72g3a. Please specify other arrangements:

73. Please specify services provided for Gambling Disorder

Yes

No

73a. Individual counseling

73b. Family counseling

73c. Group counseling

73d. Couples counseling

73e. Teen/adolescents counseling

73f. Other

73f1. Specify other:

74. Please specify documents required for first appointment

Yes

No

74a. Photo id

74b. Identification card

74c. Other

74c1. Specify other:

75. Please specify if you provide support for persons with special requirements

Yes

No

75a. Wheelchair access

75b.Language services other than English

75c. Hearing and visually impaired services

75d. Other

75d1. Specify other:

Location 6 information:

76. Contact Person First Name for appointment:

77. Contact Person Last Name for appointment:

78. Phone number to call for appointment :

79. Address:

80. City/Town:

81. State:

82. Zip/Postal code:

83. County:

84. Email address:

85. Alternative Phone Number:

86. Please indicate the days, then hours of operation:

86a. Monday

Open

Closed

Hours of operation

Yes

No

86a1. Standard hours

86a2. By appointment only

86a3. Other arrangements

86a1a. Monday standard opening

H:M

86a1b. Monday standard closing

H:M

86a3a. Please specify other arrangements:

86b. Tuesday

Open

Closed

Hours of operation

Yes

No

86b1. Standard hours

86b2. By appointment only

86b3. Other arrangements

86b1a. Tuesday standard opening

H:M

86b1b. Tuesday standard closing

H:M

86b3a. Please specify other arrangements:

86c. Wednesday

Open

Closed

Hours of operation

Yes

No

86c1. Standard hours

86c2. By appointment only

86c3. Other arrangements

86c1a. Wednesday standard opening

H:M

86c1b. Wednesday standard closing

H:M

86c3a. Please specify other arrangements:

86d. Thursday

Open

Closed

Hours of operation

Yes

No

86d1. Standard hours

86d2. By appointment only

86d3. Other arrangements

86d1a. Thursday standard opening

H:M

86d1b. Thursday standard closing

H:M

86d3a. Please specify other arrangements:

86e. Friday

Open

Closed

Hours of operation

Yes

No

86e1. Standard hours

86e2. By appointment only

86e3. Other arrangements

86e1a. Friday standard opening

H:M

86e1b. Friday standard closing

H:M

86e3a. Please specify other arrangements:

86f. Saturday

Open

Closed

Hours of operation

Yes

No

86f1. Standard hours

86f2. By appointment only

86f3. Other arrangements

86f1a. Saturday standard opening

H:M

86f1b. Saturday standard closing

H:M

86f3a. Please specify other arrangements:

86g. Sunday

Open

Closed

Hours of operation

Yes

No

86g1. Standard hours

86g2. By appointment only

86g3. Other arrangements

86g1a. Sunday standard opening

H:M

86g1b. Sunday standard closing

H:M

86g3a. Please specify other arrangements:

87. Please specify services provided for Gambling Disorder

Yes

No

87a. Individual counseling

87b. Family counseling

87c. Group counseling

87d. Couples counseling

87e. Teen/adolescents counseling

87f. Other

87f1. Specify other:

88. Please specify documents required for first appointment

Yes

No

88a. Photo id

88b. Identification card

88c. Other

88c1. Specify other:

89. Please specify if you provide support for persons with special requirements

Yes

No

89a. Wheelchair access

89b. Language services other than English

89c. Hearing and visually impaired services

89d. Other

89d1. Specify other:

Location 7 information:

90. Contact Person First Name for appointment:

91. Contact Person Last Name for appointment:

92. Phone Number to call for appointment:

93. Address:

94. City/Town:

95. State:

96. Zip/Postal code:

97. County:

98. Email address:

99. Alternative Phone Number

100. Please indicate the days, then hours of operation:

100a. Monday

Open

Closed

Hours of operation

Yes

No

100a1. Standard hours

100a2. By appointment only

100a3. Other arrangements

100a1a. Monday standard opening

H:M

100a1b. Monday standard closing

H:M

100a3a. Please specify other arrangements:

100b. Tuesday

Open

Closed

Hours of operation

Yes

No

100b1.Standard hours

100b2. By appointment only

100b3. Other arrangements

100b1a. Tuesday standard opening

H:M

100b1b. Tuesday standard closing

H:M

100b3a. Please specify other arrangements:

100c. Wednesday

Open

Closed

Hours of operation

Yes

No

100c1. Standard hours

100c2. By appointment only

100c3. By appointment only

100c1a. Wednesday standard opening

H:M

100c1b. Wednesday standard closing

H:M

100c3a. Please specify other arrangements:

100d. Thursday

Open

Closed

Hours of operation

Yes

No

100d1. Standard hours

100d2. By appointment only

100d3.Other arrangements

100d1a. Thursday standard opening

H:M

100d1b. Thursday standard closing

H:M

100d3a. Please specify other arrangements:

100e. Friday

Open

Closed

Hours of operation

Yes

No

100e1. Standard hours

100e2. By appointment only

100e3. Other arrangements

100e1a. Friday standard opening

H:M

100e1b. Friday standard closing

H:M

100e3a. Please specify other arrangements:

100f. Saturday

Open

Closed

Hours of operation

Yes

No

100f1. Standard hours

100f2. By appointment only

100f3. Other arrangements

100f1a. Saturday standard opening

H:M

100f1b. Saturday standard closing

H:M

100f3a. Please specify other arrangements:

100g. Sunday

Open

Closed

Hours of operation

Yes

No

100g1. Standard hours

100g2. By appointment only

100g3. Other arrangements

100g1a. Sunday standard opening

H:M

100g1b. Sunday standard closing

H:M

100fg3a. Please specify other arrangements:

101. Please specify services provided for Gambling Disorder

Yes

No

101a. Individual counseling

101b. Family counseling

101c. Group counseling

101d. Couples counseling

101e. Teen/adolescents counseling

101f. Other

101f1. Specify other:

102. Please specify documents for first appointment

Yes

No

102a. Photo id

102b. Identification card

102c. Other

102c1. Specify other:

103. Please specify if you provide support for persons with special requirements

Yes

No

103a. Wheelchair access

103b. Language services other than English

103c. Hearing and visually impaired services

103d. Other

103d1. Specify other:

Location 8 information:

104. Contact Person First Name for appointment:

105. Contact Person Last Name for appointment:

106. Phone Number to call for appointment:

107. Address:

108. City/Town:

109. State:

110. Zip/Postal code:

111. County:

112. Email address

113. Alternative Phone Number

114. Please indicate the days, then hours of operation

114a. Monday

Open

Closed

Hours of operation

Yes

No

114a1. Standard hours

114a2. By appointment only

114a3. Other arrangements

114a1a. Monday standard opening

H:M

114a1b. Monday standard closing

H:M

114a3a. Please specify other arrangements:

114b. Tuesday

Open

Closed

Hours of operation

Yes

No

114b1. Standard hours

114b2. By appointment only

114b3. Other arrangements

114b1a. Tuesday standard opening

H:M

114b1b. Tuesday standard closing

H:M

114b3a. Please specify other arrangements:

114c. Wednesday

Open

Closed

Hours of operation

Yes

No

114c1. Standard hours

114c2. By appointment only

114c3. Other arrangements

114c1a. Wednesday standard opening

H:M

114c1b. Wednesday standard closing

H:M