Prospective Provider Interest Form To receive an application to apply for network participation, please complete the following form. We will e-mail or send you a packet within five (5) business days.     * Required   *First Name   *Last Name   *License type   Group Name (If applicable)   E-mail address   *Mailing Address   *City   *State   *Zip   Phone Number   Fax Number   *I would like to receive my application packet by:   E-mail Fax Mail   I would like to provide the following services (check ALL that apply):   EAP Services Only Managed Care Services Only   Both EAP and Managed Care Substance abuse specialty services   Critical Incident Debriefing Services Workshop / Training   Health Fairs Elder Care   Fitness for Duty     Additional information