GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION

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GA COLLABORATIVE ASO

EXISTING AGENCY PARTICIPATION APPLICATION

To ensure timely processing of your application, please return the following checklist with all applicable documents to:

Georgia Collaborative Enrollment

240 Corporate Blvd, Suite 100

Norfolk, VA 23502

OR

Email to [email protected]

ALL APPLICANTS: Completed Application

Completed Service Location Addendum(s) - One Per Service Location (Attached)

Copy of “DBA” or trade name Registration filed with the Clerk of the Superior Court of the county of the corporation’s domicile, if the applicant operated or will operate under a trade name or “DBA”.

Copy of the Current Georgia Secretary of State registration

Copy of each site County/City Business license or permit. If not required by municipality, documentation from municipality stating not required.

Copies of all agency licenses as applicable based upon services requested, such as, Private Home Care license (PHC), Community Living Arrangement Permit (CLA), Drug Abuse Treatment and Education Program license (DATEP), Narcotics Treatment Program (NTP) Copy of current Commercial General Liability or Comprehensive General Liability insurance certificate that identifies the limits of liability of $1mil/$3mil and the policy period. The State of Georgia must be listed as Certificate Holder.

Staff Form for each service and site.

Behavioral Support Consultation (BSC)/Behavioral Suport Services (BSS) Staffing Form, if applicable Copy of each individual practitioner’s state license/certificate as required based upon services to be provided Accreditation or Standard Review Compliance Certificate(s)

TJC – The Joint Commission

CARF – Commission on Accreditation of Rehabilitation Facilities COA – Council On Accreditation

CQL – Council on Quality and Leadership

ACHC – Accreditation Commission for Health Care (Developmental Disabilities Nursing Services Only) CHAP - Community Health Accreditation Partner (Developmental Disabilities Providers Only)

DBHDD Standard Review Compliance (Developmental Disabilities Providers Only) Current Organizational Chart

Employment Attestations

All Behavioral Health Staff listed on Staff Roster

Developmental Disabilities Director, Developmental Disabilities Professional and Nurse for Developmental Disabilities services if new ACT Narrative for ACT applicants only

Controlled Substance Registration Certificate issued by the DEA – Medication Assisted Treatment (MAT) applicants only Opioid Treatment Provider Certification Letter issued by (SAMSHA) – Medication Assisted Treatment (MAT) applicants only

BEHAVIORAL HEALTH SERVICES APPLICANTS ONLY: Resume of:

o Clinical Director (CORE Services Benefit Packet Applicants Only)

o Owner

o Chief Executive Officer (CEO) and/or Director

Evidence of two (2) most recent ERO audit scores of 80% and above

DEVELOPMENTAL DISABILITIES SERVICES APPLICANTS ONLY: Resume of:

o Developmental Disabilities Professional (DDP)

o Developmental Disabilities Agency Director (DD)

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GA COLLABORATIVE ASO

Select the description(s) from the following list that best describes this request. If applying for both DD and BH services, separate applications must be submitted:

Current DBHDD Developmental Disabilities Agency Provider applying for New Service at a New Site

Current DBHDD Developmental Disabilities Agency Provider applying for New Service at a Currently Established Site Current DBHDD Behavioral Health Agency Provider applying for New Service at a New Site

Current DBHDD Behavioral Health Agency Provider applying for New Service at a Currently Established Site

I. GENERAL INFORMATION

A. Georgia Agency Legal Name: ________________________________________________________________________ DBA/Trade Name: ___________________________________________________________________________________ Address: _____________________________________________________________________________

City: _____________________ County: ___________________ State: _______________ Zip Code (9 Digits): _______________ Phone #: (___)__________________________________ TAX ID#:_________________________________________

DUNS Number, if applicable: ________________________Fiscal Year End:_________

Mailing Address (if different): ________________________________________________________________________________ City: _____________________ County: ___________________ State: _______________ Zip Code (9 Digits): _______________ B. Agency Point of Contact

Chief Executive Officer: _________________________________________

Phone: ______________________________ E-mail: _____________________

Behavioral Health Clinical Director: (Tier 2) _________________________________________ Phone: ______________________________ E-mail: _____________________

Developmental Disabilities Director: ___________________________________________________________ Phone: ____________________ Email: ____________________________________

Developmental Disabilities Professional: ___________________________________________________________ Phone: ____________________ Email: ____________________________________

Developmental Disabilities Agency Nurse (CRA and Nursing Only): ________________________________________________ Phone: ____________________ Email: ____________________________________

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GA COLLABORATIVE ASO

Person completing this application / Title: _________________________________________________________________

Phone: ____________________ Email: ____________________________________

Website Address of Agency: www._______________________________________________________________________ C. Please complete if agency is part of a corporate system:

Corporate Name: _____________________________________________________________________________ Contact Name: ________________________________________ Title: ______________________________ Primary Mailing Address: ______________________________________________________________________

City: _____________________ State: ______________ Zip Code (9 Digits): ________-______ County: ____________ Phone #: _(____)_____________________________________ Email address- (_____)_______________________ D. Business Classification (Please Check only one box for Ownership and only one box for Status)

1. Ownership: Private Public Government Program

2. Status: For-Profit Not-for-Profit

E. This organization is accredited or certified by one or more of the following: The Joint Commission (TJC)

Certificate No. _____________ Effective Date:__________ Expiration Date:__________ Commission on Accreditation of Rehabilitation Facilities (CARF)

Certificate No. _____________ Effective Date:__________ Expiration Date:__________ Council On Accreditation (COA)

Certificate No. _____________ Effective Date:__________ Expiration Date:__________ Council on Quality and Leadership (CQL)

Certificate No. _____________ Effective Date:__________ Expiration Date:__________ Accreditation Commission for Health Care (ACHC)

Certificate No. _____________ Effective Date:__________ Expiration Date:__________ Community Health Accreditation Partner (CHAP)

Certificate No. _____________ Effective Date:__________ Expiration Date:__________

Standard Compliance Review:______________________________________________ Effective Date:__________ Expiration Date:__________

F. Specify single provider number without alphas for the agency.

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GA COLLABORATIVE ASO

II. PROVIDER PROFILE QUESTIONS

PLEASE ATTACH A DETAILED EXPLANATION FOR ANY QUESTIONS BELOW THAT WERE ANSWERED “YES” A. Please answer the following questions regarding your organization’s programs:

1. Has the organization, or any other Provider Entity of which any Owner or Managing Employee is or has been an Owner or Managing Employee, had its professional liability or malpractice insurance refused, revoked,

declined or accepted on special terms in the past five (5) years? Yes No

2. Has any government agency suspended, revoked, or taken other action against the organization’s license to practice or to conduct business in the past five years, or taken such an action in the past five years against any other Provider Entity of which any Owner or Managing Employee is or has been an Owner or Managing Employee?

(To include Medicaid /Medicare) Yes No

3. Have any accreditations or memberships in professional organizations been revoked, reduced, denied, or suspended by others or voluntarily given up by the organization, or any other Provider Entity of which any Owner or Managing Employee is or has been an Owner or Managing Employee, in the last five years, or are any actions

now under way which may lead to such sanctions? Yes No

4. Has any Owner, Managing Employee, officer, or shareholder of the organization ever been convicted of a

crime, excluding minor traffic misdemeanors? Yes No

5. Has the organization, or any other Provider Entity of which any Owner or Managing Employee is or has been an Owner or Managing Employee, ever been previously denied acceptance into, disenrolled from, or withdrawn

from GA DBHDD or GA Collaborative ASO network participation? Yes No

6. Has the organization, or any other Provider Entity of which any Owner or Managing Employee is or has been an Owner or Managing Employee, had any settled claims or judgments relating to sexual misconduct or civil

rights violations in the past five years? If Yes, enter the total number: _______ Yes No 7. In the past five years, has the organization, or any other Provider Entity of which any Owner or Managing

Employee is or has been an Owner or Managing Employee, had any settled claims or judgments relating to any

other matter not disclosed in the response to Question 6 above? If Yes, enter the total number: _______ Yes No 8. Has the organization, or any other Provider Entity of which any Owner or Managing Employee is or has been an

Owner or Managing Employee, been a defendant in five (5) or more lawsuits within the past five (5) years?

If Yes, enter the total number: _______ Yes No

9. Does the organization hire, continue to employ or contract with individuals listed on the Office of Inspector General's list of Excluded Individuals/Entities (to include owners, officers, employees,

subcontractors, and others identified in § 1128)? Yes No

10. Has the organization, or any other Provider Entity of which any Owner or Managing Employee is or

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GA COLLABORATIVE ASO

MALPRACTICE CLAIM INFORMATION WORKSHEET

III. Please attach information on what the organization’s response was to the allegations and what steps were taken to prevent any future incidents for each claim listed below. This page can be copied to accommodate additional claim information.

1. Date of Occurrence: ________________ Date Claims Filed: _______________ Date of Settlement: ____________ Allegations and Action Taken: ____________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

Case Settled: In Court with Prejudice Out of Court without Prejudice

Total Amount Paid to Claimant on Behalf of Agency: ____________________________________

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GA COLLABORATIVE ASO

IV. PARTICIPATION STATEMENT -

The Georgia Department of Behavioral Health and Developmental Disabilities (DBHDD) requires that services be provided according to the service guidelines and that the agency will operate in accordance with applicable standards, rules and regulations and policies.

By signing below, I hereby certify and attest that my staff, agents, contractors, subcontractors, billing agent(s) and I have reviewed and agree to comply with the terms and conditions set forth in the applicable DBHDD and Department of Community Health (DCH)/ Medicaid Provider manuals.

I understand and acknowledge that the policies and procedures manuals are amended (generally on a quarterly basis) when either Department finds it necessary or appropriate to do so, and that it is my responsibility to check periodically for any revisions pertaining to the delivery of or

reimbursement for services rendered to eligible individuals.

I further understand that failure to abide by eitherDepartment’s (DBHDD or DCH) policies and procedures will result in adverse actions including, but not limited to the denial of claims, monetary recoupment, termination, suspension of payments, and reduction of reimbursement.

I certify and attest that I have reviewed the entire contents of the completed application and that the information provided is accurate and complete. I understand that inaccurate, incomplete or omitted data may lead to sanctions against me.

Under applicable state and federal laws, I do hereby affirm that I am the authorized agent to complete this document and that the information contained herein this document is complete, true, and correct to the best of my knowledge. I understand that material misrepresentation and/or falsification of any information contained herein shall result in the immediate removal of further consideration for participation. ___________________________________________ Agency Name ___________________________________________ Date (mm/dd/yy): _____/______/______ Authorized Signature ___________________________________________ Name (Please Print)

___________________________________________ Title

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GEORGIA COLLABORATIVE DISCLOSURE OF OWNERSHIP FORM

For DBHDD

Directions: In order to comply with Federal law (42 CFR 420.200 - 420.206 and 455.100- 455.106) health plans with Medicaid or Medicare business are required to obtain certain information regarding the ownership and control of entities with which the health plan contracts for services for which payment is made under the Medicaid or Medicare program or any line of business that provides healthcare for federal employees. The Centers for Medicaid and Medicare Services (CMS) requires the Georgia Collaborative to obtain this information to demonstrate that we are not contracting with an entity that has been excluded from federal and state health programs, or with an entity that is owned or controlled by an individual who has been convicted of a criminal offense, has had civil monetary penalties imposed against them, or has been excluded from participation in Medicare or Medicaid.

Please complete the following 3 pages below. This form is required if you wish to participate or continue to participate in the plan. You are also reminded that any changes to this information in the future must be reported to the Georgia Collaborative within 35 business days of the change and updated information will be requested upon recredentialing. Please provide information for Owners, persons with Control interests, Agents and Managing employees of the Provider Entity. Attach a separate sheet/report if needed. If the company is a non-profit please put N/A in % ownership column. Definitions:

Owner (1) is a person or business entity which owns 5% or more of the assets, stock or profits of the Provider Entity. This

5% may be Direct ownership or Indirect ownership i.e., an individual might own 50% of a company that owns the actual Provider Entity meaning their indirect ownership is 50%. In addition to ownership of stock, (2) Owner is also a person who owns a legal obligation like a mortgage or loan that is secured by the assets of the Provider Entity.

Control Interest is someone who directs the Provider Entity and includes Directors, Trustees and Officers of Corporations

and Partners in a Partnership. If the Provider Entity is a non-profit entity, respond N/A in the column for % of ownership.

Managing Employee is someone who makes the day to day decisions for the Provider Entity. These individuals include

office or billing managers for smaller providers, and for larger Provider Entities the heads of the major operating groups of the provider like, Head of Accounting, or Director of same day services. In other words, the line of individuals typically listed below the corporate officers on an organizational chart.

Agent is an individual who has the legal ability to bind the Provider Entity, i.e., the Provider Entity may use an Agent to

obtain contracts for it.

Debarred or Excluded means an individual or entity that is not allowed to do business with the Federal government,

including healthcare programs receiving Federal funding or reimbursement.

Terminated means the Provider lost the right to bill a State’s Medicaid or CHIP programs for a cause related to fraud or

abuse.

Immediate Family is defined as a person's husband or wife; natural or adoptive parent; child or sibling; stepparent,

stepchild, stepbrother or stepsister; father-, mother-, daughter-, son-, brother- or sister-in-law; grandparent or grandchild; or spouse of a grandparent or grandchild. Member of Household is, with respect to a person, any individual with whom they are sharing a common abode as part of a single family unit, including domestic employees and others who live together as a family unit. A roomer or boarder is not considered a member of household.

A Subcontractor is a person or company that this Provider Entity has contracted with to do some of the Provider Entities’

management functions, i.e., billing agent, or provide medical services i.e. a medical lab.

Supplier means an individual, agency, or organization from which the Provider Entity purchases goods and services used

in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer of hospital beds or a pharmacy.)

Master List: The list of owners the provider will be disclosing on form.

Provider Entity: Any individual or entity engaged in the delivery of health care services in a State and is licensed or

certified by the State to engage in that activity in that State if such licensure or certification is required by State law or regulation

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GA COLLABORATIVE OWNERSHIP DISCLOSURE FORM

I. IDENTIFYING INFORMATION

Name of person Completing form Phone number of person completing form

Provider Name:

Provider Entity Name _{Provider Entity DBA Name}

(if different from Provider Entity name)

Provider Entity Federal Tax Id number

Provider Entity NPI Number

(If you have one, if not indicate if applicable )

Provider Entity Medicaid ID number

(If you have one, if not indicate if applied for.)

Provider Entity Telephone Number

Provider Entity Address- Must include at least one street address. List all Practice locations (attach a separate sheet if needed).

City State Zip

II. OWNER OR CONTROL INFORMATION

A. Master List- If attaching reports please indicate corresponding columns below.

Name

Address

(For individuals use Home address. For business entities that might have Ownership/Control interest use all street addresses (if more than one location), and P.O. Box address if any.)

City ST ZIP DOB

SSN for individuals or Tax ID for business entities % own er- ship. _Title B. Specific Questions

1) Is any person on the Master List related to another person on the Master List as a spouse, parent, child or sibling? If attaching a report, please indicate corresponding columns below.

Yes  No  If yes, please provide the following information about the related persons:

Name of First related person Name of Second related Person Type of relationship

2) Does any person or entity in the Master List have an Ownership or Control interest in any other Provider Entity? If attaching a report, please indicate corresponding columns below.

Yes  No  If “yes”, please provide the following information about the other Provider Entity the person on the Master List has an interest in.

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GA COLLABORATIVE OWNERSHIP DISCLOSURE FORM

3) Have any of the individuals or entities on the Master list been convicted of a criminal offense related to that person’s involvement in any program under Medicare, Medicaid, Tricare or the CHIP services program since the inception of those programs?

Yes  No . If yes, please provide the information requested below:

Name on Court

records SSN /TIN Matter of the Offense

Date of the Conviction

Exclusion Period of the Offense if you were excluded

by the Federal Office of the Inspector General(OIG)

4) Have any of the individuals or entities on the Master List ever been Debarred or Excluded from participation in Federal Government contracts (Medicaid, Medicare, CHIP or Tricare)?

Yes  No  If ‘yes’ is checked, provide the following information:

When you were

debarred Length of Debarment Reason for Debarment

Has any person or entity on the Master List ever been Terminated or had Civil Monetary Penalties from a State’s Medicaid or CHIP programs for reasons having to do with Program Integrity (fraud or abuse)?

Yes  No  If “Yes”, please supply the following information:

State where practicing when terminated

Reason for termination Date of

termination

5) Did anyone on the Master List obtain their Direct or Indirect Ownership interest 1) as a result of a transfer of Direct or Indirect ownership from someone who was about to be Excluded or Terminated from participation in a Federal healthcare program, or was in fact Excluded or terminated from participation in a federal healthcare program and 2) where the original Owner is or was a member of the current Owner‘s Immediate Family or Member of the current owner’s household, at the time of the transfer of ownership? If attaching a report, please indicate corresponding columns below.

Yes  No  If “Yes”, please supply the following information:

Name of original Owner SSN or TAX ID of original Owner Place of Transfer Date of Transfer

7a) List any Subcontractor in which this Provider Entity has a Direct or Indirect Ownership interest of at least a 5%. A

Subcontractor is a person or company that this Provider Entity has contracted with to do some of the Provider Entities’

management functions, i.e., billing agent, or provide medical services i.e. a medical lab. If attaching a report, please indicate corresponding columns below.

Name of Subcontractor Address City State Zip Tax I.D.

7b) For each Subcontractor(s) listed in 7a above please provide the following information for the individuals with an Direct or Indirect

Ownership or Control Interest in the Subcontractor(s). See the Introduction section above for a definition of those terms. Attach a separate sheet if necessary. If attaching a report, please indicate corresponding columns below.

Name Address (for individuals use Home address, for

business entities that might have Ownership/Control interest use all street addresses (if more than one

location), and P.O. Box address (if any)

City ST Zip DOB SSN orTax ID % of own

er- ship

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GA COLLABORATIVE OWNERSHIP DISCLOSURE FORM

7c) Is anybody in the list in 7b list related to any person in the Master List above? If attaching a report, please indicate corresponding columns below.

Yes  No  If yes, please supply the following information about the related persons:

Name of First related person Name of Second related Person Type of relation

III. BUSINESS TRANSACTIONS

1) Please list the Subcontractors with whom you have done business over the last 5 years where the contract is worth at least 5% of your Provider Entities’ total operating expenses or $25,000 whichever is less. Use a separate sheet if necessary. Do not include the Subcontractors listed in II.7a. in which you have an Direct or Indirect Ownership interest. If attaching a report, please indicate corresponding columns below.

Name Address City State Zip

2) Does the Provider Entity wholly own a Supplier? If attaching a report, please indicate corresponding columns below. Yes  No  If yes, supply the following information about the Supplier:

Name Address City State Zip NPI TIN

Answer the following questions by checking '"Yes" or "No'•. If any of the questions are answered "Yes," list names and addresses of individuals or corporations and/or provide date and an explanation.

1. Has there been a change in ownership or control within the last year? If yes, give date and provide

an explanation: ________________________________________________ Yes  No

2. Do you anticipate any change of ownership or control within the year? If yes, provide date and explanation.

______________________________________________________________ Yes No

3. Do you anticipate filing for bankruptcy within the year? If yes, when? _____________________________ Yes No

4. Is this facility, agency, institution or organization operated by a management company, or leased in whole

or part by another organization? If yes, give date of change in operations and provide explanation. Yes No

______________________________________________________________

5. Has there been a change in CEO, DD Director, DDP, Clinical Director, or Medical Director within the last year?

Yes No

6. Is this facility, agency, institution or organization chain affiliated?

(If yes, list name, address of Corporation, and EIN) _________________________________________ Yes No

IV.SIGNATURE

Department of Behavioral Health and Developmental Disabilities (DBHDD) may refuse to enter into, renew, or terminate an agreement with a Provider if it is determined that a Provider did not fully, accurately, and truthfully make the disclosures required by this statement. Additionally, false statements or representations of the required disclosures may be prosecuted under applicable federal or state laws. 42 C.F.R. § 455.106. The signature below MUST be the written signature of an individual who can legally bind this Provider Entity;

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SERVICE LOCATION ADDENDUM

INSTRUCTIONS: COMPLETE ONE PAGE PER SERVICE LOCATION (PHOTOCOPY AS NEEDED)

SERVICE LOCATION: BILLING ADDRESS: (Please confer with your Billing Dept) Site Name:_________________________________

Address Line 1: ___________________________________ Address Line 1: ___________________________________ Address Line 2: ___________________________________ Address Line 2: ___________________________________ City, State, ZIP (9 Digit): ___________________________________ City, State, Zip (9 Digit): ____________________________ Phone Number: ___________________________________ Phone Number: ___________________________________ NOW Medicaid Number (if applicable): _____________________ COMP Medicaid Number (if applicable): __________________ Community Behavioral Health Rehabilitation Service (CBHRS)/Medicaid Rehab Option (MRO) Number if applicable: ___________ Counties Requested:

___________________________________________________________________________________________

This location is:

Yes No - Accessible by Public Transportation Yes No - Americans with Disabilities Act Compliant Yes No - Host HomeIf “Yes” include copy of Host Home Self Study This site is licensed by Healthcare Facility Regulation (HFR) as a: (Include a copy of the license)

Behavioral Health (BH) Services:

Drug Abuse Treatment and Education Program License

Narcotics Treatment Program License

 Not Applicable

Developmental Disabilities (DD) Services:

Child Caring Institution (CCI) Only applicable for Respite Personal Care Home (PCH) Only applicable for Respite

Child Placing Agency (CPA) Private Home Care (PHC)

Community Living Arrangement (CLA) Not Applicable

Home Health Agency (HHA)

SERVICES REQUESTED AT LOCATION

BEHAVIORAL HEALTH (PLEASE CHECK AGE GROUP APPLICABLE

CHILD & ADOL (4-17) ADULT (18+)

CORE BENEFIT PACKAGE

SUBSTANCE ABUSE INTENSIVE OUTPATIENT (SAIOP) AMBULATORY SUBSTANCE ABUSE DETOXIFICATION ASSERTIVE COMMUNITY TREATMENT (ACT)

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GA COLLABORATIVE SERVICE LOCATION ADDENDUM

SERVICES REQUESTED AT LOCATION

Child & Adol (4-17)

COMMUNITY SUPPORT TEAM (CST) INTENSIVE CASE MANAGEMENT (ICM) INTENSIVE FAMILY INTERVENTION (IFI) MEDICATION ASSISTED TREATMENT (MAT)

PEER SUPPORT - MENTAL HEALTH (Groups and Individuals) PEER SUPPORT - ADDICTIVE DISEASES (Groups and Individuals ) PEER SUPPORT – WHOLE HEALTH AND WELLNESS

PSYCHOSOCIAL REHABILITATION – (Groups and Individuals)(PSR)

TASK ORIENTED REHABILITATION SERVICES (TORS) MUST BE STATE FUNDED SUPPORTED EMPLOYMENT PROVIDER

DEVELOPMENTAL DISABILITIES(PLEASE CHECK WAIVER APPLICABLE NOW COMP HIPAA

CODE

BEHAVIORAL SUPPORTS CONSULTATION – 15 MINUTES H2019

BEHAVIORAL SUPPORTS SERVICES – 15 MINUTES H2019 U1

COMMUNITY ACCESS – GROUP SERVICES T2025 HQ

COMMUNITY ACCESS – GROUP SERVICES – CO-EMPLOYER T2025 HQ

UA

COMMUNITY ACCESS – INDIVIDUAL SERVCES T2025 UB

COMMUNITY ACCESS – INDIVIDUAL CO-EMPLOYER T2025

UB/UA

COMMUNITY LIVING SUPPORT SERVICES – 15 MINUTES T2025 U5

COMMUNITY LIVING SUPPORT – 15 MINUTES CO EMPLOYER T2025

U5/UA

COMMUNITY LIVING SUPPORT SERVICES – DAILY T2025 U6

COMMUNITY LIVING SUPPORT SERVICES– DAILY CO-EMPLOYER T2025

U6/UA

COMMUNITY RESIDENTIAL ALTERNATIVE SERVICES T2033

ENVIRONMENTAL ACCESSIBILITY ADAPTATION S51656

NATURAL SUPPORT TRAINING SERVICE T2025 UD

PREVOCATIONAL SERVICES T2015

RESPITE SERVICES – 15 MINUTES S5150

RESPITE SERVICES – 15 MINUTES CO-EMPLOYER S5150 UA

RESPITE SERVICES OVERNIGHT S5151

RESPITE SERVICES – OVERNIGHT CO-EMPLOYER S5151 UA

BEHAVIORAL HEALTH (PLEASE CHECK AGE GROUP APPLICABLE

BEHAVIORAL HEALTH (PLEASE CHECK AGE GROUP APPLICABLE Adult

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GA COLLABORATIVE SERVICE LOCATION ADDENDUM

SERVICES REQUESTED AT LOCATION

DEVELOPMENTAL DISABILITIES(PLEASE CHECK WAIVER APPLICABLE NOW COMP HIPAA

CODE

NURSING SERVICES - REGISTERED NURSE (RN) T1002 U1

NURSING SERVICES - LICENSED PRACTICAL NURSE (LPN) T1003 U1

SPECIALIZED MEDICAL SUPPLIES T2028

SPECIALIZED MEDICAL EQUIPMENT T2029

SUPPORT COORDINATION T2022

SUPPORTED EMPLOYMENT SERVICES - GROUP T2019 HQ

SUPPORT EMPLOYMENT SERVICES – GROUP - CO-EMPLOYER T2019

HQ/UA

SUPPORTED EMPLOYMENT SERVICES – INDIVIDUAL T2019 UB

SUPPORTED EMPLOYMENT SERVICES – INDIVIDUAL - CO-EMPLOYER T2019

UB/UA

TRANSPORTATION – ENCOUNTER/TRIP T2003

TRANSPORTATION – ENCOUNTER/TRIP - CO-EMPLOYER T2003 UA

TRANPORTATION – COMMERCIAL CARRIER - MULTI-PASS T2004

VEHICLE ADAPTATIONS T2039

OCCUPATIONAL THERAPY (OT) -EVALUATION 97003

OCCUPATIONAL THERAPY (OT) -THERAPEUTIC ACTIVITIES 97530 GO

OCCUPATIONAL THERAPY (OT) -SENSORY INTEGRATIVE TECHNIQUES 97533 GO

PHYSICAL THERAPY (PT) -EVALUATION 97001

PHYSICAL THERAPY (PT) -THERAPEUTIC PROCEDURES 97110

SPEECH & LANGUAGE – EVALUATION 92523

SPEECH & LANGUAGE – THERAPY 92507 GN

SPEECH-GENERATING DEVICE THERAPY 92609

Attestation Statement:

My signature below indicates that all of the information provided above, and in any attachments to this application document, is complete and correct to the best of my knowledge.

Name: _____________________________________________________ Title: _________________________ Signature: __________________________________________________ Date: _________________________

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Developmental Disabilities -- Attestation of the Agency Director

The minimum responsibilities of the agency’s Director are specified below. My signature indicates that I have read these responsibilities, discussed them with (agency representative or Owner or CEO)

_______________________________________________________________________________ Name of Agency Representative or Owner or CEO

I agree that I will be employed by this agency and accountable for meeting each of these requirements. I also agree that I have reviewed my resume submitted by this agency and agree that it accurately reflects both my education and experience.

Duties of the Agency Director include, but are not limited to: Overseeing the day-to-day operation of the agency; Managing the use of agency funds;

Ensuring the development and updating of required policies of the agency; Managing the employment of staff and professional contracts for the agency; Designating another agency staff member to oversee the agency in my absence.

________________________________ _____________________________________

Signature Date

________________________________________ Printed Name

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Attestation of the Agency Developmental Disabilities Professional (DDP)

The minimum responsibilities of the agency’s DDP are specified below. My signature indicates

that I have read these responsibilities, discussed them with (agency representative or Owner

or CEO)

_____________________________________________________________________________ Name of Agency Representative or Owner or CEO

I agree I will be employed by this agency and accountable for meeting each of these

requirements. I also agree that I have reviewed my resume submitted by this agency and

agree that it accurately reflects both my education and experience.

At least one agency employee or professional under contract with the agency must be a

Developmental Disabilities Professional (DDP) (for definition, see

Part II Policies and

Procedures for COMP

,

Appendix I);

Duties of the DDP include, but are not limited to:

Overseeing the services and supports provided to participants;

Supervising the formulation of the participant‘s plan for delivery of

all waiver services provided to the participants by the provider;

Conducting functional assessments; and

Supervising high intensity services.

_______________________________________ _____________________________________

Signature Date

________________________________________ Printed Name

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Developmental Disabilities -- Attestation of the Agency Registered Nurse

All agencies providing CRA services must employ or contract with a Registered Nurse (RN). All agencies providing Nursing specific services must employ or contract with the appropriately licensed nurse as designated in the service description. My signature indicates that I have read these responsibilities, discussed them with (agency representative or Owner/CEO):

Name of Agency Representative or Owner/CEO

I a gr e e that I will be employed or contracted by this agency and accountable for meeting these requirements. I have reviewed my resume and license submitted by this agency and agree that they accurately reflect both my education and experience.

Duties of the Agency RN for includes, but are not limited to:

• Review of medications policy and documentation of compliance for delivery • Assessment of participant’s nursing needs

• Initial healthcare plan(s) development (based upon assessed needs, risks, and active conditions) • Development of teaching plan and caregiver(s) competency checklist;

• Implementation of ordered/indicated clinical and nursing interventions • Preparation of clinical progress notes

• Coordination of healthcare services

• Informing the physician, support coordination and other personnel of changes in the patient’s condition or needs

• Patient and family teaching

• Supervision (to be performed by RN) and teaching of other provider personnel (clinical and other direct support staff)

• Administering medications and treatments as prescribed by a physician in accordance with currently accepted standards of nursing practice

• Other services in accordance with and as outlined in the Georgia Registered Professional Nurse Practice Act

My signature indicates that I have reviewed these responsibilities and I am prepared to accept them as defined.

Signature of Nurse Date:

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Behavioral Health Services

STAFFING FORMS

Please complete the appropriate Staffing Form(s) for each

location, each service you included in your Letter of Intent.

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STAFFING FORM: ADULT CORE BENEFIT PACKAGE

Complete an Adult Core Staffing Form for each Adult Core location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

City: County: State: Zip:

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

AM PM By Appt.

NOTE: Positions indicated with an asterisk (*) below are the minimum staffing requirements for this service. All positions listed with an asterisk must have staff names in addition to the applicable licenses or certificates. “To Be Hired” (TBH) and any other notation which shows a failure to properly staff ready and qualified personnel will not be accepted. Include a copy of all applicable licenses or certificates, a current resume and list the specific days and hours worked in this service for each staff member listed.

Position Title Name License/Certificate

Type, Number and Expiration Date

Number of Hours Per Week

Clinical Director* (Minimum one per agency) Must be fulltime position Physician*

Must be on site to provide direct services a minimum of 10 hours weekly per site.

Physician’s Assistant; Advanced Practice RN; Clinical Nurse Specialist; or Nurse Practitioner

Psychologist

Registered Nurse (RN)* Must be on site to provide direct services a minimum of 10 hours weekly per site.

Licensed Professional Nurse (LPN)

Licensed Clinicians* (LCSW, LPC, LMFT)

May be part-time or full-time position Associate Licensed Clinicians (LMSW, LAPC, LAMFT)

Addiction Practitioner*

(MAC, CACII, CADC, CCADC, GCADC II, GCADC III)May be part-time or full-time

Certified Peer Specialists* Minimum 2 Full Time Equivalent (FTE) Paraprofessional(s)*

(19)

STAFFING FORM: C&A CORE BENEFIT PACKAGE

Complete a C&A Core Staffing Form for each C&A Core location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

NOTE: Positions indicated with an asterisk (*) below are the minimum staffing requirements for this service. All positions listed with an asterisk must have staff names in addition to the applicable licenses or certificates. “To Be Hired” (TBH), and any other notation which shows a failure to properly staff ready and qualified personnel will not be accepted. Include a copy of all applicable licenses or certificates, a current resume and list the specific days and hours worked in this service for each staff member listed.

Position Title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Clinical Director*

(Minimum one per agency) Must be fulltime position

Physician*

Must be on site to provide direct services a minimum of 10 hours weekly per site.

Physician’s Assistant; Advanced Practice RN; Clinical Nurse Specialist; or Nurse Practitioner

Psychologist

Registered Nurse (RN)*

Must be on site to provide direct services a minimum of 10 hours weekly per site.

Licensed Professional Nurse (LPN)

Licensed Clinicians*

(LCSW, LPC, LMFT)

May be part-time or full-time position

Associate Licensed Clinicians

(LMSW, LAPC, LAMFT)

Addiction Practitioner *

(MAC, CACII, CADC, CCADC, GCADC (II, III)

May be part-time or full-time position

Paraprofessional(s)*

(20)

STAFFING FORM: SUBSTANCE ABUSE INTENSIVE OUTPATIENT (SAIOP) SERVICES

Complete a SAIOP Staffing Form for each SAIOP location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

Population:

□

Adult

□

Child & Adolescent

AM PM By Appt.

Position title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Clinical Supervisor* Physician* Physician’s Assistant; Advanced Practice RN; Clinical Nurse Specialist; or Nurse Practitioner

Psychologist

Registered Nurse (RN)* Licensed Professional Nurse (LPN)

Licensed Clinicians*

(LCSW, LPC, LMFT

Associate Clinicians*

LMSW, LAPC, LAMFT)

Addiction Practitioner* (MAC,

CACII, CADC, CCADC, GCADC II, GCADC III)

(21)

STAFFING FORM: AMBULATORY SUBSTANCE ABUSE DETOXIFICATION

Complete an Ambulatory Substance Abuse Detoxification Staffing Form for each Ambulatory Substance Abuse Detoxification location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Please note that this service is also covered by Drug Abuse Treatment Programs Rule 290-4-2. Reflect all the required staff on the above form. Please refer to the DBHDD Provider Manual Service Guidelines for Staffing Requirements.

Site Address:

AM PM By Appt.

NOTE: Positions indicated with an asterisk (*) below are the minimum staffing requirements for this service. All positions listed with an asterisk must have staff names in addition to the applicable licenses or certificates. “To Be Hired” (TBH), and any other notation which shows a failure to properly staff ready and qualified personnel will not be accepted. Include a copy of all applicable licenses or certificates and a current resume, and list the specific days and hours worked in this service, for each staff member listed.

Position Title Name License /

Certificate Type, Number and Expiration Date

Number of Hours Per Week

Medical Doctor /Psychiatrist*

On-call Physician

Physician’s Assistant

Nursing Staff:

Clinical Nurse Specialist* Registered Nurse (RN)* Licensed Practical Nurse (LPN)*

(22)

STAFFING FORM: ASSERTIVE COMMUNITY TREATMENT (ACT)

Complete an ACT Staffing Form for each ACT location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Team Leader * Psychiatrist* Registered Nurse (RN)* Licensed Clinicians* (LCSW, LPC, LMFT) Associate Clinicians* (LMSW, LAPC, LAMFT) Addiction Practitioner*

(CACI, MAC, CACII, CADC, CCADC, GCADC II, GCADC III)

Certified Peer Specialist* Vocational Rehabilitation Specialist*

Paraprofessional(s)* Other

(23)

STAFFING FORM: COMMUNITY SUPPORT TEAM (CST)

Complete a CST Staffing Form for each CST location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Team Leader * Psychiatrist Registered Nurse (RN)* Licensed Clinicians (LCSW, LPC, LMFT) Associate Clinicians (LMSW, LAPC, LAMFT) Addiction Practitioner

Certified Peer Specialist*

Paraprofessional(s)*

(24)

STAFFING FORM: INTENSIVE CASE MANAGEMENT (ICM) SERVICES

Complete an ICM Staffing Form for each ICM location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License / Certificate Type,

Number and Expiration Date

Number of Hours Per Licensed Supervisor * Case Manager* Case Manager* Case Manager* Case Manager* Case Manager* Case Manager* Case Manager* Case Manager* Case Manager* Case Manager* Other

(25)

STAFFING FORM: INTENSIVE FAM ILY INTERVENTION

Complete an IFI Staffing Form for each IFI location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License / Certificate Type,

Number and Expiration Date Number of Hours Per Week TEAM NUMBER: #: Team Leader* Licensed Clinician (LCSW, LPC, LMFT) Paraprofessional* Paraprofessional* Paraprofessional

(26)

STAFFING FORM: Medication Assited Treatment (MAT)

Complete a Medication Assited Treatment (MAT) Staffing Form for each Medication Assited Treatment (MAT) location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Include a copy of the following for each site:

• Opioid Treatment Program Certificate issued by SAMSHA

• Controlled Substance Registration Certificate issued by DEA

Site Address:

AM PM By Appt.

Position Title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Program Physician* Clinical Director*

(CACII, CADCII, MAC, LPC, LCSW, LMFT, CAS with Bachelor’s degree)

Physician’s Assistant; Advanced Practice RN; Psychologist

Licensed Professional Nurse (LPN) Licensed / Certified Practitioner*

(LPC, LCSW, LMFT, CACII, CACI, CADCII, CADCI, MAC, CAS with Bachelor’s degree)

Associate Licensed Clinicians

Addiction Practitioner(s)

(CACII, CADCII, CCADC, C A S )

(27)

STAFFING FORM: PEER SUPPORT – MENTAL HEALTH SERVICES

i. Peer Support - Mental Health - Groups

ii. Peer Support - Mental Health - Individuals

Complete a Peer Support Mental Health Services Staffing Form for each Peer Support Mental Health Services location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

City: County: State: Zip:

AM PM By Appt.

Position Title Name License / Certificate

Type, Number and Expiration Date

Number of Hours Per Week Program Leader *

Certified Peer Specialist* Certified Peer Specialist* Certified Psychiatric Rehabilitation Professional (CPRP) Licensed Clinicians (LCSW, LPC, LMFT) Associate Clinicians (LMSW, LAPC, LAMFT) Other

(28)

STAFFING FORM: ADDICTIVE DISEASES - PEER SUPPORT

i. Addictive Diseases Peer Support - Group

ii. Addictive Diseases Peer Support - Individual

Complete an Addictive Diseases Peer Support Services Staffing Form for each Addictive Diseases Peer Support Services location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License / Certificate

Number of Hours Per Week Supervisor*

(MAC, CACII, GCADCII,III)

Program Leader *

Certified Peer Specialist - AD (CARES)

Certified Peer Specialist

Certified Peer Specialist –AD (CARES)

Certified Psychiatric Rehabilitation Professional (CPRP)

Certified Peer Specialist (CPS)

Addiction Practitioner

(29)

Staffing Form: Peer Support – Whole Health and Wellness

Complete a Peer Support – Whole Health and Wellness Services Staffing Form for each Peer Support – Whole Health and Wellness Services location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License / Certificate

Number of Hours Per Week Whole Health and Wellness

Coach* (CPS Whole Health Action Management (WHAM) Certified)

Whole Health and Wellness Coach (CPS Whole Health Action Management (WHAM) Certified)

Licensed Clinician

(LCSW, LPC, LMFT)

Certified Peer Specialist

(Whole Health Action

Management (WHAM) Certified)

(30)

STAFFING FORM: PSYCHOSOCIAL REHABILITATION (PSR)

Complete a Psychosocial Rehabilitation Services Staffing Form for each Psychosocial Rehabilitation Services location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Program Supervisor*

Certified Psychiatric Rehabilitation Practitioner (CPRP) Clinical Supervisor* (LCSW, LPC, LMFT) Certified Psychiatric Rehabilitation Practitioner* Licensed Clinicians (LCSW, LPC, LMFT)

Associate Licensed Clinicians

Certified Peer Specialist

Addiction Practitioner (CACI, MAC,

CACII, CADC, CCADC, GCADC II, GCADC III)

(31)

STAFFING FORM: Task Oriented Rehabilitation Services (TORS

Complete a Task Oriented Rehabilitation Services Staffing Form for each Task Oriented Rehabilitation Services location. Duplicate as needed. It is your duty to read the DBHDD Provider Manual Service Guidelines for Staffing Requirements. It is your responsibility and duty to fully adhere to the requirements of the DBHDD Provider Manual Service Guidelines.

Site Address:

AM PM By Appt.

Position Title Name License /

Certificate Type, Number and Expiration Date Number of Hours Per Week Program Supervisor*

Certified Psychiatric Rehabilitation Practitioner (CPRP) Employment Specialist* Certified Psychiatric Rehabilitation Practitioner Licensed Clinicians (LCSW, LPC, LMFT)

Associate Licensed Clinicians

Certified Peer Specialist Paraprofessional

(32)

Developmental Disabilities Services

STAFFING FORM (Not for BSC and BSS)

Staffing Form: List all staff assigned to proposed service at site (use additional sheets if necessary):

Name of Waiver Service: _______________________________________________________________________

Site Address:

POSITION TITLE NAME Number of Hours Per Week

(33)

Developmental Disabilities Services

STAFFING FORM for BSC and BSS

Staffing Form: List all staff assigned:

Submit the following for each employee listed:

1. Current Resume

2. Evidence of specialized training and education

3. Professional License or Certificate

Name of Waiver Service: BSC BSS

Site Address:

POSITION TITLE NAME Number of

Hours Per Week

BSC/ BSS Developmental Disabilities Professional (DDP)

Behavior Support Consultant (BSC) Behavior Support Consultant (BSC) Behavior Support Consultant (BSC) Behavior Support Consultant (BSC) Behavior Support Consultant (BSC)

Behavior Support Services Consultant (BSS) Behavior Support Services Consultant (BSS) Behavior Support Services Consultant (BSS) Behavior Support Services Consultant (BSS) Behavior Support Services Consultant (BSS)

Please note that the DDP for BSC and BSS must:

•

Have a minimum of a Master’s degree in psychology, education, social work or a related field, and

(34)

Behavioral Health Employment Attestations

(must complete one form for each staff listed on the Staffing Form)

Each staff member listed on the Staffing form must complete an Employment Attestation.

Name Phone Email License number if applicable Expiration date Certificate number if applicable Expiration date Hire date Position Service Service location Select one:

I have a written contract with the agency and work the following number of hours per week in this position. ______ I am an employee of the agency and work the following number of hours per week in this position. ______

Indicate specific hours worked in this position in the grid below.

Monday Tuesday Wednesday Thursday Friday Saturday Sunday

AM PM By Appt.

I, hereby attest that I am employed in the position listed above.