Become a Quest Provider | Quest Behavioral Health and EAP Services

Complete the Provider Pre-Application form below to get started. Pre-Applications will be reviewed by the Quest Credentialing Committee for eligibility. Qualified applicants will receive a full credentialing application within 30 days of committee decision. For questions, call the Provider Relations Department at 717-851-1478 or email provider@questbh.com.
* indicates a required field
Individual Applicant Name*
First Last
Contact Name*
First Last
Contact Email*
Date of Birth (mm/dd/yyyy):*
Primary Office
Primary Office Name*
Primary Office Address*
Street Address Address Line 2 City State ZIP Code
Primary Office County*
Primary Practice Type*
- Group
- Solo
Practice Information
Age Groups
- Young Child (0-5)
- Child (6-12)
- Adolescent (13-17)
- Adult (18-64)
- Geriatrics (65+)
Provider Type
- SAP Provider
- Fitness for Duty Provider
Disorders
- ADHD - Attention Deficit Disorders
- AU - Autism/Developmental Disorders
- DIS - Dissociative Disorders
- DDX - Dual Diagnosis
- EDO - Eating Disorders
- GEN - General
- ODD - Oppositional Defiant Disorders
- PD - Personality Disorders
- PH - Phobias/Anxiety Disorders
- PTSD - Post Traumatic Stress Disorders
- SA - Substance Abuse/Addictions
- SD - Sexual Disorders/Dysfunction
Specialty Areas
- Bio - Biofeedback
- CBT - Cognitive-Behavioral Therapy
- Ect - Electro-Convulsive Treatment
- Fam - Family/Couples Therapy
- Gr - Group Therapy
- Hiv - HIV/AIDS
- Hyp - Hypnosis
- Pain - Pain Management
- Play - Play Therapy
- Ptest - Psychological Testing
- PtestN - Neuropsycholgical Testing
- Scc - Spiritual/Christian Counseling
Cultural/Language Specialty Areas
- Cas - Cultural, Asain
- Caf - Cultural, African-American
- Ch - Cultural, Hispanic
- G&L - Gay and Lesbian
- L - Language - Other
- LS - Language, Spanish
- SL - Sign Language
- W - Women's Issues
Licensure
License Number
Original License Date
Month
Day
Year
License Expiration Date
Month
Day
Year
DEA Registration*
DEA Expiration Date*
Month
Day
Year
Board Certified*
Board Certified Date*
Month
Day
Year
Specialty
Board Eligible*
Board Eligible Date*
Month
Day
Year
Education & Training (for highest degree received)
College/University*
Address*
Degree*
Graduation Date*
Month
Day
Year
Name when degree was awarded*
Honors/Publications
Internship Information
Internship Institution
Address
Type/Study
Attended from/to
Completed
Residency Information
Residency Institution
Address
Specialty
Attended from/to
Completed
Professional References
Reference 1
Reference Name*
First Last
Degree
License*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Phone
Email
Reference 2
Reference Name*
First Last
Degree
License*
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Phone
Email
I fully understand that if any information provided in this application is false, or becomes false, without my giving notification to Quest Behavioral Health by certified mail within 15 days of such information becoming false, Quest Behavioral Health will be entitled to terminate my provider agreement for breach. All information submitted by me in this application is warranted to be true, correct, and complete. I authorize Quest Behavioral Health and/or its Agents to consult with the National Practitioner Data Bank, state licensing board(s) educational institutions, specialty boards, malpractice insurance carriers, Educational Council for Foreigh Medical Graduates, hospitals, professional references, and any other person or entity from whom/which information may be needed to complete the credentialing process or to obtain and verify information concerning my membership, professional competence, character and moral and ethical qualifications, and I hereby authorize all of them to release such information to Quest Behavioral Health and/or its Agents. I release Quest Behavioral Health, its employees and Agents and all those whom Quest Behavioral Health and/or its Agents contact from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application. I consent to the release by any person to Quest Behavioral Health and/or its Agents of all information that may reasonably be relevent to an evaluation of my professional competency, character and moral and ethical qualification, including any information relating to any disciplinary action or suspension or curtailment of privileges, and hereby release any such person providing such information from any and all liability for doing so.*
I fully understand that if any information provided in this application is false, or becomes false, without my giving notification to Quest Behavioral Health by certified mail within 15 days of such information becoming false, Quest Behavioral Health will be entitled to terminate my provider agreement for breach. All information submitted by me in this application is warranted to be true, correct, and complete.

I authorize Quest Behavioral Health and/or its Agents to consult with the National Practitioner Data Bank, state licensing board(s) educational institutions, specialty boards, malpractice insurance carriers, Educational Council for Foreigh Medical Graduates, hospitals, professional references, and any other person or entity from whom/which information may be needed to complete the credentialing process or to obtain and verify information concerning my membership, professional competence, character and moral and ethical qualifications, and I hereby authorize all of them to release such information to Quest Behavioral Health and/or its Agents. I release Quest Behavioral Health, its employees and Agents and all those whom Quest Behavioral Health and/or its Agents contact from any and all liability for their acts performed in good faith and without malice in obtaining and verifying such information and in evaluating my application.

I consent to the release by any person to Quest Behavioral Health and/or its Agents of all information that may reasonably be relevent to an evaluation of my professional competency, character and moral and ethical qualification, including any information relating to any disciplinary action or suspension or curtailment of privileges, and hereby release any such person providing such information from any and all liability for doing so.
- I agree

Employee Assistance Programs and Administration of Behavioral Health Benefits

Join the Quest Behavioral Health Provider Network.

Primary Office

Practice Information

Education & Training (for highest degree received)

Internship Information

Residency Information

Professional References

Reference 1

Reference 2