CareLink Network Provider Application
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COMPLETION OF THIS APPLICATION DOES NOT GUARANTEE A CONTRACT WITH CARELINK NETWORK
Instructions: Please complete one application for each organization and include unique service information for each
site where care will be provided. Each organization with a separate Tax Identification Number must have a separate
application. Please legibly print or type the information on the application. Incomplete applications may be returned.
If you have additional questions or concerns, please call the contracting department at 313-656-0000.
Please attach the following documents with each application:
Copy of all current accreditations (NCQA, JCAHO/TJC, CARF, AOA, COA, other); Include accreditation certificates and letters.
Copy of any current state licenses and certificates
Copy of general and professional liability insurance (minimum of $1 mil/$3mil will required for contracting)
Completed W-9 form (can be obtained at www.CareLinknetwork.org or on the IRS website)
Signed Direct Care Wage Attestation Form, if applicable
Copy of organizational chart
Staff Roster for residential providers only (page 7 – all information must be entered)
Number of FTEs (Full Time Equivalent)___________
Resume of Licensee/Provider – residential facilities only (Resumes of Direct Care Workers are not required)
For Free Standing Psychiatric Hospitals (or IMDs) only – copy of the Agreement for Provision of Medical Care Services How many CareLink members are you currently providing services for? ____________________________________________ How many years of experience does the organization have servicing people with mental illness (MI)?
______________________________________________________________________________________________________ Describe: ____________________________________________________________________________________________________ ____________________________________________________________________________________________________________ Does anyone in your organization speak other languages fluently? No ☐ Yes ☐ Please list according to each site identified on the next page: ______________________________________________________________________________________________ A. General Information (Please print)
Corporation: ______________________________________________________________________________________ Mailing /Billing Address: _______________________________________________________________________________ City: ____________________________________State: _____________________________Zip Code: _______________ Telephone #: ( ___ ) _______________ Alternate #: ( ____ )
Facsimile #: Email Address:
Website address: ________________________________________________________________________ Have you ever contracted with another MCPN? ☐ Yes ☐ No
If so, which site and which MCPN?
Was the contract ever terminated? ☐ Yes ☐ No Reason
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List addresses for ALL sites you are applying for where services will be provided under the corporation listed on the first page; include the License, Insurance and Accreditation information if applicable. (If additional pages are needed, this page may be copied.)
1. Site Name: __________________________________________________________________________________________ Site Address: _________________________________________Cross Streets: _________________________________ City: _________________________ State: _________________ Zip Code: ________________ County: _________________ Site Telephone #: ( _____ ) __________________________ Site Fax Number: ( ___ ) ____________________________ Site Contact Person: ____________________________________________Title: ____________________________________ Contact Person Phone Number: __________________________ Contact Person email: ______________________________ Residential providers: Capacity: _______ Vacancies: ________Style of Home (ranch, colonial etc.):_____________________ Are languages other than English spoken in this facility? ☐ No ☐ Yes-List language (s)______________________________ Wheelchair Accessible (inside & outside of facility) ☐ Yes ☐ No First Floor bedroom? ☐ Yes ☐ No
Barrier Free Inside? ☐ Yes ☐ No
Do you provide transportation? ☐ Yes ☐ No Family Live In? ☐ Yes ☐ No Willing to accept: Age range_____________________ Rate range:__________________ ☐ Male ☐Female ☐ Both Number of CareLink members at this facility: __________ *Total number of people served at this site: ___________ * Please include all consumers
____________________________________________________________________________________________________ 2. Site Name
Site Address: _________________________________________Cross Streets: _________________________________ City: ________________________ State: ________________ Zip Code: _______________ County: ____________________ Site Telephone #: ( ) ________________________________ Site Fax Number: ( )_______________________________ Site Contact Person: ____________________________________________Title: ____________________________________ Contact Person Phone Number: __________________________ Contact Person email: ______________________________ Residential providers: Capacity: _______ Vacancies: ________Style of Home (ranch, colonial etc.):_____________________ Are languages other than English spoken in this facility? ☐ No ☐ Yes-List language (s)______________________________ Wheelchair Accessible (inside & outside of facility) ☐ Yes ☐ No First Floor bedroom? ☐ Yes ☐ No
Barrier Free Inside? ☐ Yes ☐ No
Transportation provided to clients? ☐ Yes ☐ No Family Live In? ☐ Yes ☐ No Willing to accept: Age range_____________________ Rate range:__________________ ☐ Male ☐Female ☐ Both Number of CareLink members at this facility: __________ * Total number of people served at this site: ___________
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B. Contact Person(s) for the Corporation
1. Primary Contact: ____________________ Phone Number: ___________________ Email: ____________________ Title: ________________________________ Alternative Number: _______________
2. Alternative Contact: _________________ __ Phone Number: ___________________ Email: ____________________ Title: _________________________________ Alternative Number: ________________
3. President/CEO/Owner: _________________ Phone Number: ____________________ Email: ____________________ Title: ________________________________ Alternative Number: ________________
4. Billing Contact: ________________________ Phone Number: ____________________ Email: ____________________ Title: ________________________________
5. Person Completing Application: __________________________ Telephone Number: __________________________
C. Classification of Business (all that apply)
☐
Private☐
Public☐
Not-for-profitTax ID Number: ______________________________ NPI Number: ________________________________
____________________________________________________________________________________________________________ D. If facility/program is a subsidiary of, in partnership with, or administratively organizationally linked with another entity,
please provide the following information regarding each entity. If not applicable, indicate N/A.
Corporate Name: ______________________________________________________________________________________ DBA/Trade Name: _____________________________________________________________________________________ Primary Mailing Address: ________________________________________________________________________________ City: ____________________ State: ____________________Zip Code: ___________________County: _________________ Telephone Number (_____ ) _____________ Fax Number: (_____ ) __________________E-Mail: ______________________
E. Accreditation/Certifications (Check yes or no), attach copy of certificate and accreditation letter: NCQA: ☐ Yes ☐ No If yes, indicate Expiration Date: ________________________________ TJC/JCAHO ☐ Yes ☐ No If yes, indicate Expiration Date: ________________________________ CARF ☐ Yes ☐ No If yes, indicate Expiration Date: ________________________________ AOA ☐ Yes ☐ No If yes, indicate Expiration Date: ________________________________ COA ☐ Yes ☐ No If yes, indicate Expiration Date: ________________________________ Other ☐ Yes ☐ No If yes, indicate Expiration Date: ________________________________
Medicaid Certified ☐ Yes ☐ No Number: __________________ Expiration Date: __________________ Medicare Certified ☐ Yes ☐ No Number: __________________ Expiration Date: __________________ F. Legal Description of Program/Facility:
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G. Liability/Insurance Information – Please complete AND attach a copy of the certificate:
Name of Liability Carrier: _______________________________________________________________________________ Policy Number: ____________________ Effective Date: ____________________ Expiration Date: _____________________ Professional and General
Liability Limits: Per Occurrence: ____________________________ Aggregate: ____________________________ H. General Liability History
This information will be reviewed in order to determine acceptance or denial of this application for credentialing or re-credentialing. If you respond “yes” to any of the questions below, please submit an explanation of the situation or event involved (specific client names may be deleted), and the actions taken, including pending status. Such documentation should include, but is not limited to the following:
Sanction letters and/or related documents from any licensing, certifying or credentialing entity
Settlement agreements, petitions, complaints, responses and letters of demand concerning malpractice claims that name the organization or specific program
Claim history from your insurance company for the last three years
Description of relevant quality improvement activities or changes resulting from the sanction, lawsuit, settlement. 1. Has the facility/program been named in any malpractice action over the last five years? ☐ Yes ☐ No 2. Has the facility/program been named in any currently pending legal actions? ☐ Yes ☐ No 3. Has any government agency investigated, suspended, revoked or taken other action
against the facility/program’s license to conduct business within the past five years? ☐ Yes ☐ No 4. Has the facility/program had professional liability insurance revoked, suspended,
declined, or accepted on special terms over the last five years? ☐ Yes ☐ No 5. Has the facility/program members or staff been removed, sanctioned or suspended from
membership in a professional association for violation(s) of its ethical code of practice
within the last five years? ☐ Yes ☐ No
6. Has the facility/program, members of the program, or staff been penalized, expelled or suspended from receiving payment under the Medicaid or Medicare programs within the
last five years? ☐ Yes ☐ No
7. Have any facility/program owners, or staff been convicted of a crime excluding
misdemeanors? ☐ Yes ☐ No
8. Have any facility/program owners, officers ever had or have an IRS levy instituted? ☐ Yes ☐ No I. Fiscal Stability
1. Provide a copy of the organization’s most recent financial statement, along with the preparer’s
name
address
telephone number
2. List the name and address of any CareLink Network Board member or employee with whom a staff member or director of the organization has had a substantial financial relationship with the past twelve (12) months on page 5. If not applicable, indicate N/A.
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Name of Organization
: ___________________________________________________________________________________ List CareLink Network, board member(s), staff or affiliates with whom a member of the applicant’s organization has had a financial relationship within the past twelve (12) monthsName Address Organization Position
1.____________________________________ ___________________________________ _____________________________ 2.____________________________________ ___________________________________ _____________________________ 3.____________________________________ ___________________________________ _____________________________ 4.____________________________________ ___________________________________ _____________________________ 5.____________________________________ ___________________________________ _____________________________ _________________________________________________________________________________________________________ List of all debts owed to, or loans obtained from a CareLink Network board member or employee by a staff member or director of the organization:
Name Address Organization Position
1.____________________________________ ___________________________________ _____________________________ 2.____________________________________ ___________________________________ _____________________________ 3.____________________________________ ___________________________________ _____________________________ 4.____________________________________ ___________________________________ _____________________________ 5.____________________________________ ___________________________________ _____________________________
CareLink Network Board of Directors
Nicole Wells Stallworth
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J. Provider Services - Usual and Customary Fees:
Please select the service(s) that your agency has the ability and is requesting to provide by marking an “x” in the box to the left of the service description and indicate your usual and customary fees.
Selection Service Description Usual and Customary
Fees
☐ Assessment/Evaluation S
☐ Case Management $
☐ Clubhouse/Peer Directed/Consumer Run $
☐ Community Living Support $
☐ Family Skills Development $
☐ Home Based Services (must be approved by MDHHS and enrolled with DWMHA) $
☐ Inpatient Mental Health $
☐ Intensive Crisis Stabilization (must be approved by MDHHS and enrolled with DWMHA) $
☐ Medication Administration $
☐ Mental Health Therapy/Counseling $
☐ Nursing/Private Duty Nursing $
☐ Occupational Therapy $
☐ Outpatient Partial Hospital Services (must be approved by MDHHS and enrolled with DWMHA) $
☐ Person Centered Planning $
☐ Personal Care Services $
☐ Physical Therapy $
☐ Psychosocial Rehabilitation (must be approved by MDHHS and enrolled with DWMHA) $
☐ Respite Services $
☐ Skill Building $
☐ Speech/Language Therapy $
☐ Supports Coordination $
☐ Supported Integrated Employment Services $
☐ Supported Housing $
☐ Wraparound Services (must be approved by MDHHS and enrolled with DWMHA) $ If other, please specify
Selection Service Description Usual and Customary
Fees ☐ $ ☐ $ ☐ $ ☐ $ ☐ $
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Staff Roster – for Residential only
If additional pages are needed, this page may be copied.
1. Staff Name: _____________________________________ FTE Yes ☐ ☐ No Date of Hire: ___________________ Criminal Background Check Conducted: ☐ Yes ☐ No Date: ___________________ Most recent dates for: Direct Care Worker Training: ____________________ Medication Training: ___________________
Recipient Rights Training: ____________________ First Aid Training: ____________________ CPR Training: ____________________
Credentials, certifications or other trainings
(Substance Abuse Training, Blood Borne Pathogen Trainings etc.):__________________________________________________ ________________________________________________________________________________________________________ Location(s) staff is employed: ________________________________________________________________________________ ________________________________________________________________________________________________________ --- --- 2. Staff Name: _____________________________________ FTE Yes ☐ ☐ No Date of Hire: ____________________ Criminal Background Check Conducted: ☐ Yes ☐ No Date: ____________________ Most recent dates for: Direct Care Worker Training: ____________________ Medication Training: ____________________
Recipient Rights Training: _____________________ First Aid Training: ____________________ CPR Training: _____________________
Credentials, certifications or other trainings
(Substance Abuse Training, Blood Borne Pathogen Trainings etc.):__________________________________________________ ________________________________________________________________________________________________________ Location(s) staff is employed: ________________________________________________________________________________ ________________________________________________________________________________________________________ --- 3. Staff Name: _____________________________________ FTE Yes ☐ ☐ No Date of Hire: ____________________ Criminal Background Check Conducted: ☐ Yes ☐ No Date: ____________________ Most recent dates for: Direct Care Worker Training: ____________________ Medication Training: _____________________ Recipient Rights Training: _____________________ First Aid Training: _____________________
CPR Training: _____________________ Credentials, certifications or other trainings
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Provider Application for Credentialing
Release Authorization and Ethical Commitment
The Applicant hereby has submitted an application for appointment to the Provider Panel of CareLink Network. The Applicant certifies that the information provided is true, complete and correct. The Applicant expressly agrees that any information entered into this document that is subsequently found to be false or inaccurate are grounds for immediate contract termination and removal from the provider network. The Applicant agrees to maintain general and professional liability coverage as stated in this document and as required by the Detroit Wayne Mental Health Authority.
The Applicant authorizes CareLink Network or its designee to obtain and verify information contained on the application and consents to release all persons, organizations, including other networks or other entities of liability in any respect because of having furnished information as a result of this application.
The Applicant authorizes investigation of all statements contained in this application and specifically authorizes CareLink Network or its designee to investigate any and all information that may be reasonably relevant to an evaluation of, but not limited to, the organization’s licensure, accreditation, absence from the Office of Inspector General’s (OIG) and Excluded Parties List (EPLS) sanction list and potential exclusion from Medicare or Medicaid. The Applicant releases CareLink Network and its designees from any liability for any reports, records, recommendations, claims information and claims history, or any other information given in good faith and related to the credentialing process. The Applicant further understands that participation and continued participation as a provider for CareLink Network is dependent upon successful completion of the credentialing process and the impaneling process for the Detroit Wayne Mental Health Authority, as applicable. A photocopy of this authorization shall be deemed equivalent to the original. The Applicant understands and agrees that misrepresentation or omission of facts called for is grounds for termination from the Provider Panel.
I certify that I am authorized to make the above warranties, representations and releases on behalf of this provider organization and to sign this application on behalf of this organization.
Criminal background checks must be done on all new hires and annually thereafter. Signing this form confirms this process is completed by the organization.
_____________________________________ _____________________________________ Name of Provider Organization (Print) Name of Authorized Representative (Print) _____________________________________ _____________________________________
Date Signature of Authorized Representative
RETAIN A COPY OF THIS APPLICATION FOR YOUR FILES
