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Expedited Application for Provider Status

Physicians, nurse practitioners, and physician assistants who have experience in providing child sexual abuse evaluations and have provided a minimum of 100 child sexual abuse evaluations within the past 3 years can apply to be designated CHAMP Providers using an expedited application.

The application process has these steps:

  1. Submit an Expedited Provider application along with a current CV

  2. Submit 3 letters of reference with one being from a current or most recent supervisor and one being from a current CHAMP Mentor (If your supervisor is a current CHAMP Mentor, only 2 letters of reference are needed.)

  3. Submit documentation of completing the CHAMP coursework Evaluating Child Sexual Abuse (either a copy of the post-test results or a copy of the CME certificate)

  4. You will also be asked to submit three of your most current child sexual abuse cases. The review requires submitting photodocumentation as well as written information. The case review forms do not contain information that identifies the patient. Your cases will be reviewed by CHAMP Mentors who have been blinded to your identity. After you submit your application and supporting materials, Linda Markell will send you the case review forms.

After your cases have been reviewed, Linda Markell will forward all your materials to the Application Committee of the CHAMP Advisory Board for consideration.

If you are approved to be a Provider, you will be invited to be part of the CHAMP Network and be listed as a Provider on the CHAMP website www.CHAMPprogram.com .

You can download the Expedited Provider application (PDF) or request that one be mailed to you. If you need help with downloading or opening the PDFs, please see below.

If you have questions or need an application, please contact Linda Markell, CHAMP Manager.
Markelll@upstate.edu
Phone: 315-464-2047
Fax: 315-464-2048


HELP with the PDF forms
To view the PDF, you will need the free Acrobat Reader.
To fill out the form, please download the PDF document to your computer, print and fill it out, and return by mail.
To download:

  1. For PCs, right click on the form or PDF link
  2. From the pop-up menu that opens, select Save Link As (or Save Target As)
  3. In the Save As dialog box, select the folder where you would like the file saved
  4. For Macs, click the link to open and then save

Once the file is downloaded to your computer:

  1. Go to the folder where you saved the file
  2. Double-click the file to open the PDF
  3. Print the form
  4. Complete the form and return by mail
NOTE If you experience difficulties with downloading or opening the PDF, try downloading the file with Internet Explorer.