MFLC Program Screening Application / Questionnaire

Pre-Screening Questions


Question 1



Check all that apply OR if you are not local to any of these bases check "I am not local to any of these bases listed below".


Enter Information Below

First
Middle
Last

2.Address

Address Line 1
Address Line 2
City
State
Zip Code
Country
Type
State
License Number
Type
State
License Number
Type
State
License Number

8. Are you contracted with MHN for any other line of business (such as Commercial business or TRICARE)?:

9. Have you previously applied to or been a participant in the MHN Government Services Military & Family Life Counselor Program?

10. MHN obtains credentialing information from CAQH. Do you have a current CAQH Number? (list if you have one)

11. Are you a previous MHN or Health Net employee? If yes, please elaborate with specific job title, location, and timeframe of employment. Please include Employee ID if you know it.

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How did you learn about the MFLC program/opportunity - please indicate all that apply:

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Recruitment Code:
If you have not been provided a recruitment code, please leave this field blank.
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