Becoming an ESI Employee Assistance Group Service Provider
- 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
- W9 Tax ID Form
Please return completed application with supporting documentation to our Corporate Office:
ESI Employee Assistance Group
Mail: 55 Chamberlain Street, Wellsville, NY 14895