Geisinger Health Plan Behavioral Health Professional Services Questionnaire Completed Form Examples and Samples

Subject: Dr. Sarah Miller - New Practitioner Profile for Geisinger Credentialing

To: Credentialing Department
From: Practice Management, Evergreen Counseling & Wellness
Date: March 10, 2026

Dear Credentialing Team,

This memo provides the necessary information to update our records and complete the Geisinger Health Plan Behavioral Health Professional Services Questionnaire for our newest licensed psychologist, Dr. Sarah Miller. She officially joined our team at Evergreen Counseling & Wellness on March 1st. We're really excited to have her expertise.

Dr. Miller holds a Psy.D. degree and is a fully Licensed Psychologist in Pennsylvania. Her National Provider Identifier (NPI) is 1234567890. Our main office, where Dr. Miller will primarily see clients, is located at 450 Maple Avenue, Suite 200, Harrisburg, PA 17101. This is in Dauphin County. She will be working Monday through Friday, 9 AM to 5 PM, though we are discussing offering some evening hours in the future. The best contact number for patient inquiries and referrals is our main office line, 717-555-0199. Our office fax number, if needed, is 717-555-0198.

Regarding her patient population, Dr. Miller primarily serves adults (ages 18-64) and adolescents (13-17), but also has experience and accepts geriatric patients (ages 65 and older). She does not typically work with children aged 12 or younger, as her clinical focus has been on older populations. For communication, Dr. Miller is fluent in English and Spanish, and can also converse adequately in Portuguese, which she picked up during her doctoral research abroad in Brazil. She is looking forward to integrating into the community.

Dr. Miller brings extensive experience in several key areas. She specializes in PTSD and Trauma, Obsessive Compulsive Disorder, Addiction/Substance Use Disorders, and Chronic Pain Management. She also has a strong focus on LGBTQ+ Issues. She does not specialize in Autism Spectrum Disorders or Eating Disorders, though she can provide referrals for those. Her license number is PS001234.

Her therapeutic services include Acceptance and Commitment Therapy (ACT), Cognitive Behavioral Therapy (CBT), Dialectical Behavioral Therapy (DBT), Eye Movement Desensitization and Reprocessing (EMDR), Trauma Informed Psychotherapy (including CPT, PE), and Interpersonal Psychotherapy (ITP). She also provides Group Psychotherapy, Individual Psychotherapy, Couples/Marital Therapy, Family Therapy, Anger Management, Behavioral Modification, Psychological Testing, and Addiction, Recovery, and Relapse Prevention Counseling. Telemedicine/Telehealth Services are offered for all appropriate clients. She has a strong commitment to Veteran's Services, particularly for post-deployment and reintegration support.

Conditions she is willing to treat if referred include Abuse, Assault, and Trauma (PTSD), Addiction/Substance Use Disorders, Affective (Mood) Disorders, Anxiety Disorders, Bipolar Disorder, Co-Occurring Disorders, Chronic Pain Management, Depression, Divorce/Blended Family Issues, Domestic Violence History and/or PTSD, Gender Transition/Identity Issues, LGBTQ+ Issues, Men’s Issues, Obsessive-Compulsive Disorder, Pain Management/Pain Psychology, Recent Trauma (Acute Stress), and Women’s Issues. She does not work with sexual offender history cases or provide services for sexual dysfunction.

Evergreen Counseling & Wellness offers an Intensive Outpatient Program (IOP) for adults (18-64) dealing with General Mental Health disorders and Substance Use Disorders. Dr. Miller will be involved in these adult IOP programs, primarily facilitating group sessions. We do not offer PHP at this location, nor do we have specialized PHP/IOP for children, adolescents, or geriatrics, or for eating disorders. Our next staff meeting is scheduled for next Tuesday.

Dr. Miller's email is [email protected].

Please let us know if any further details are required.

Sincerely,
Practice Management