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Individual Applications

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Board Certified Behavior Analyst Application


Physical, Speech, Occupational, Respiratory Therapist, Audiologist Application

Clinical Psychologist Application 


Physician Assistant Application

Clinical Social Worker Application           


Physician and Dentist Application

Marriage, Family and Pastoral Application


Psychiatric Nurse Specialist Application 

Mental Health Counselor Application  


Registered Dietitian, Nutritionist Application 

Nurse Anesthetist, Anesthesia Assistant Application                


RN, LPN, Nurse Midwife, Nurse Practitioner Application



All provider applications should be returned to the following address or fax:


Provider Data Management
P.O. Box 870156
Surfside Beach, SC 29587-9756
FAX:  1-888-279-3540