MHRS Provider Employment Application

Section I - Position & Agency Information

All fields must be completed, and each required file must be uploaded to its matching field. Incomplete applications cannot be processed.

Position Applied For:

Employment Type:

Full-Time

Part-Time

Conntractor

Start Date (or ASAP):

Section II - Identification

Full Legal Name:

Address:

Phone Number (Cell/Home):

Email:

DC Residency:

Yes

(If no, specify state):

Government-issued photo ID:

Section III - Education

Highest Degree Earned:

Institution:

Graduation Date:

Diploma/Degree:

Section IV - Employment History (Last 5 Years)

Resume/CV:

Section V - References

Full Name:

Relationship:

Email:

Phone:

Full Name:

Relationship:

Email:

Phone:

Section VI - Clinicians

Upload all clinical licenses. Licenses must be current. Provide a copy of your liability insurance from the company of your choice. Coverage must be current.

Clinical license(s):

Liability insurance:

CAQH #:

Section VII - Background & Compliance

Background Clearance Disclosure (Required)

I acknowledge that, in accordance with the Department of Behavioral Health (DBH) and Our Community Support Services (OCSS) policies, individuals with fraud-related charges on any background clearance are not eligible for employment. I confirm that, to the best of my knowledge, I do not have any fraud-related charges on my background clearances.

FBI and police clearances must be dated within the last 4 years. Applicants for clinician positions do not need to submit FBI or police clearances.

FBI clearance:

Local police clearance:

Child Protection Register (CPR) clearance: Request it through CFSA. Enter this on the form:

Request purpose: Employment
Employer: Our Community Support Services, 210 55th Street NE, Washington, DC 20019
Requestor email: kofi.graham@ourcommunitysupport.com
Requestor phone: (202) 258-9100

Section VIII - Health Screening

TB and drug test documents must be dated within the current year.

TB test:

Drug test:

Section IX - NPI & Medicaid Affiliation

You need an NPI number and Medicaid affiliation. Get your NPI number first, then complete your Medicaid affiliation. Your NPI number must be affiliated with OCSS.

NPI number: Get one through NPPES.

Create an account
Login and select apply for an NPI
I am applying for an Individual NPI

NPI number:

Medicaid Affiliation for Community Support Workers

Community support workers complete the DBH Streamlined application. Do not use the Standard application; it is for clinicians.

Once you have an NPI number, log in to DC PDMS and create an application.
Complete the DBH Streamlined application.
Affiliate with Our Community Support Services:
- Provider name: Our Community Support Services
- NPI: 1710750617
- Medicaid ID: 000003187
- Taxonomy: 261QM0801X

Medicaid Affiliation for Clinicians

Clinicians complete the Standard application. Do not use the DBH Streamlined application; it is for community support workers.

Once you have an NPI number, log in to DC PDMS and create an application.
Complete the Standard application.
Affiliate with Our Community Support Services:
- Provider name: Our Community Support Services
- NPI: 1710750617
- Medicaid ID: 000003187
- Taxonomy: 261QM0801X

Need help with your Medicaid affiliation? Contact Maximus at 844-218-9700. A representative can walk you through the process.

Section X - Training and Certifications

CPR/First Aid certification: Submit your current certificate (available through AED CPR). Don't have one? OCSS will train you.

CPR/First Aid certification:

Mandated Reporter Training: Complete the CFSA Mandated Reporter Training and submit your certificate.

Mandated Reporter certificate: