How to Join Our FCC Network

If you would like to be a part of a team that is committed to providing excellent coaching and
counseling support, please join our network – complete the provider information form.

Join Our
FCC Workforce Wellness
Network

Thank you for your interest in joining the FCC Workforce Wellness network. You must have a valid Clinical License ( or completed certification) in your specialty area ( Psychiatry, Psychology, Mental Health Counselor, Social Worker, or Wellness Coach Certification)

Please be aware that this form is an inquiry for consideration and not an official registration. We will review your request and if we need your specialty, a representative will contact you to help guide you through our formal application process. Thank you again for your interest.

Please leave this field empty if you don't have a fax number
If you don't have a CAQH ID please leave this field empty.
Please list your specialty here

Attestation Statement and Authorization to Release Information


I hereby apply to become a Specialist practitioner in the FCC Workforce network. I certify that all of the information that I have submitted in connection with the application is true, accurate, and complete. I understand that FCC will rely on this information to evaluate my participation.

I understand and agree that I am to adhere to and abide by the terms and conditions of this program(s) and all Agreements I have or will in the future enter into with FCC.

I understand that any material misstatement or omission of fact on the application is grounds for action by FCC, including but not limited to summary dismissal from FCC as provided in the Provider Agreement.

I attest to having in the amounts required by the My Licensing State current, valid malpractice insurance coverage and all other applicable professional insurances.

I agree to adhere to the code of ethics of the Professional Organization*

I authorize FCC and/or its designated credentialing agent to consult with members of the medical staff, affiliate hospitals, professional liability carriers, and healthcare facilities with which I have been associated. In addition, this authorization includes consultation with other healthcare professionals who may have information bearing on my competency, character, physical health status, emotional health status, and ethical aspects of my professional practice.

I authorize the release of such information to FCC and/or its designated credentialing agent upon request. I agree a facsimile or photocopy of my signature will serve the same as the original.

I agree to release all Medical Assistance records pertaining to sanctions and/or settlements to FCC