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Provider Letter of Interest

Enthea is creating employer-sponsored benefit plan coverage for both ketamine-assisted psychotherapy (KAP) and psychedelic-assisted psychotherapy (PAP). This coverage will allow for reliable, fair and prompt reimbursement for clinical services rendered. We are offering benefit plans to employers starting with ketamine-assisted psychotherapy. MDMA-assisted psychotherapy and psilocybin-assisted psychotherapy coverage is planned for 2024.

We are currently seeking letters of interest from mental health professionals who wish to explore participating in the Enthea provider network as KAP providers now and/or PAP providers in the future (including therapists and prescribers). If you are interested in learning more, we would love to hear from you.

Please complete the following brief survey and letter of interest. This will allow for a channel of communication to keep you informed about the opportunity of network participation. Of course, your information will be kept confidential. We are a growing organization, so we sincerely appreciate your patience in advance. Thank you for sharing your time with us today.

Business Information

Legal Business NameDBA (Doing Business As)

CityPrimary Contact First Name

State/RegionPrimary Contact Last Name

Primary Contact Title

Primary Contact Phone Number

Primary Contact Email

Tell us what services you provide:
Behavioral Health Services
Ketamine Services
MDMA Assisted Therapy (as study or Expanded Access site)
Psilocybin Assisted Therapy (as study)
Other

Business Information

WebsiteHow many licensed clinicians work at your organization?How did you hear about us?Is there any other information you want us to know?

Letter of Interest

I am interested in learning more about participating in the Enthea Provider Network. By submitting this non-binding letter of interest, I understand that:

1. I will be offered additional information about network participation and the network contracting process.
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2. Enthea will set certain standards for services provided through its benefit plans. My potential participation in the Network requires that I meet certain compliance requirements and fulfill certain administrative obligations, as will be set forth in the Provider Agreement.

3. If I wish to join the Enthea Provider Network, my professional credentials, facilities, staff may be reviewed by Enthea representatives prior to being offered a Provider Agreement. I understand the credential review process is the first of many collaborative experiences involved in being an Enthea provider.

4. Following credential review, I will receive a written Provider Agreement at Enthea’s sole discretion. I will have the opportunity to review any such Agreement prior to my participation in the Enthea Provider Network. I am under no obligation to sign, and I may opt out of network participation at my discretion in the future.

5. This Letter of Interest does not guarantee my acceptance into the Enthea Provider Network.

6. If I enter into a Provider Agreement with Enthea, it will not affect my rights to participate with any other network.

First Name

Last Name

Company Name

Date

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