Provider Application

Becoming an ESI Employee Assistance Group Service Provider

Mandatory Requirements:

  • State Licensure as a Behavioral Health Professional with at least a Master’s Degree.
  • Minimum and current Malpractice Liability Insurance Coverage of $1,000,000/$3,000,000.
  • Empanelment with at least one major/area Behavioral Health Insurance plan.

Please complete and sign the Service Provider Application Form and include:

  • Professional Malpractice Liability Insurance Face Sheet
  • State Licensure or Registration with Expiration Date
  • Resume
  • W9 Tax ID Form

Please return completed application with supporting documentation to our Corporate Office:

ESI Employee Assistance Group

Fax: 585-593-6311

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