GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION

Transcription

1 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 OR to 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) o Developmental Disabilities (DD) Registered Nurse (RN) (DD CRA and Nursing Services Applicants Only)

2 GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION 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: Behavioral Health Clinical Director: (Tier 2) Phone: Developmental Disabilities Director: Phone: Developmental Disabilities Professional: Phone: Developmental Disabilities Agency Nurse (CRA and Nursing Only): Phone:

3 GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION Person completing this application / Title: Phone: 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 #: _( ) 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. MEDICAID # (Please provide supporting documentation)

4 GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION 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 has been an Owner or Managing Employee, filed for Bankruptcy in the past five years? Yes No

5 GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION 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: 2. 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: 3. 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: 4. 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:

6 GA COLLABORATIVE ASO EXISTING AGENCY PARTICIPATION APPLICATION 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 either Department 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 Authorized Signature Date (mm/dd/yy): / / Name (Please Print) Title

7 GEORGIA COLLABORATIVE DISCLOSURE OF OWNERSHIP FORM For DBHDD Directions: In order to comply with Federal law (42 CFR and ) 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

8 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 ership. 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. Name of other Provider Entity Address City State Zip Tax I.D.

9 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 ership Title

10 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: 2. Do you anticipate any change of ownership or control within the year? If yes, provide date and explanation. Yes No 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 The signature below MUST be the written signature of an individual who can legally bind this Provider Entity; Name of Person (Printed) Signature of Person Title Date

11 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 2: Address Line 1: Address Line 2: City, State, ZIP (9 Digit): City, State, Zip (9 Digit): Phone Number: NOW Medicaid Number (if applicable): Phone Number: 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 Home If 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 CORE BENEFIT PACKAGE SUBSTANCE ABUSE INTENSIVE OUTPATIENT (SAIOP) AMBULATORY SUBSTANCE ABUSE DETOXIFICATION ASSERTIVE COMMUNITY TREATMENT (ACT) CHILD & ADOL (4-17) ADULT (18+)

12 BEHAVIORAL HEALTH (PLEASE CHECK AGE GROUP APPLICABLE GA COLLABORATIVE SERVICE LOCATION ADDENDUM SERVICES REQUESTED AT LOCATION BEHAVIORAL HEALTH (PLEASE CHECK AGE GROUP APPLICABLE COMMUNITY SUPPORT TEAM (CST) Child & Adol (4-17) Adult (18+) 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 BEHAVIORAL SUPPORTS CONSULTATION 15 MINUTES BEHAVIORAL SUPPORTS SERVICES 15 MINUTES COMMUNITY ACCESS GROUP SERVICES COMMUNITY ACCESS GROUP SERVICES CO-EMPLOYER COMMUNITY ACCESS INDIVIDUAL SERVCES COMMUNITY ACCESS INDIVIDUAL CO-EMPLOYER COMMUNITY LIVING SUPPORT SERVICES 15 MINUTES COMMUNITY LIVING SUPPORT 15 MINUTES CO EMPLOYER COMMUNITY LIVING SUPPORT SERVICES DAILY COMMUNITY LIVING SUPPORT SERVICES DAILY CO-EMPLOYER COMMUNITY RESIDENTIAL ALTERNATIVE SERVICES ENVIRONMENTAL ACCESSIBILITY ADAPTATION NATURAL SUPPORT TRAINING SERVICE PREVOCATIONAL SERVICES RESPITE SERVICES 15 MINUTES RESPITE SERVICES 15 MINUTES CO-EMPLOYER RESPITE SERVICES OVERNIGHT RESPITE SERVICES OVERNIGHT CO-EMPLOYER HIPAA CODE H2019 H2019 U1 T2025 HQ T2025 HQ UA T2025 UB T2025 UB/UA T2025 U5 T2025 U5/UA T2025 U6 T2025 U6/UA T2033 S51656 T2025 UD T2015 S5150 S5150 UA S5151 S5151 UA

13 GA COLLABORATIVE SERVICE LOCATION ADDENDUM SERVICES REQUESTED AT LOCATION DEVELOPMENTAL DISABILITIES(PLEASE CHECK WAIVER APPLICABLE NOW COMP NURSING SERVICES - REGISTERED NURSE (RN) NURSING SERVICES - LICENSED PRACTICAL NURSE (LPN) SPECIALIZED MEDICAL SUPPLIES SPECIALIZED MEDICAL EQUIPMENT SUPPORT COORDINATION SUPPORTED EMPLOYMENT SERVICES - GROUP SUPPORT EMPLOYMENT SERVICES GROUP - CO-EMPLOYER SUPPORTED EMPLOYMENT SERVICES INDIVIDUAL SUPPORTED EMPLOYMENT SERVICES INDIVIDUAL - CO-EMPLOYER TRANSPORTATION ENCOUNTER/TRIP TRANSPORTATION ENCOUNTER/TRIP - CO-EMPLOYER TRANPORTATION COMMERCIAL CARRIER - MULTI-PASS VEHICLE ADAPTATIONS HIPAA CODE T1002 U1 T1003 U1 T2028 T2029 T2022 T2019 HQ T2019 HQ/UA T2019 UB T2019 UB/UA T2003 T2003 UA T2004 T2039 OCCUPATIONAL THERAPY (OT) -EVALUATION OCCUPATIONAL THERAPY (OT) -THERAPEUTIC ACTIVITIES OCCUPATIONAL THERAPY (OT) -SENSORY INTEGRATIVE TECHNIQUES GO GO PHYSICAL THERAPY (PT) -EVALUATION PHYSICAL THERAPY (PT) -THERAPEUTIC PROCEDURES SPEECH & LANGUAGE EVALUATION SPEECH & LANGUAGE THERAPY GN SPEECH-GENERATING DEVICE THERAPY 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:

14 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

15 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

16 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: Printed Name of Nurse GA RN License No.

17 Behavioral Health Services STAFFING FORMS Please complete the appropriate Staffing Form(s) for each location, each service you included in your Letter of Intent.

18 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: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 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 Number of Hours Per Week 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 fulltime Certified Peer Specialists* Minimum 2 Full Time Equivalent (FTE) Paraprofessional(s)* May be part-time or full-time position

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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 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 Number of Hours Per Week 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)* May be part-time or full-time position

20 STAFFING FORM: SUBSTANCE ABUSE INTENSIVE OUTPATIENT (SAIOP) SERVICES Site Address: 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. City: County: State: Zip: Population: Adult Child & Adolescent AM PM By Appt. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Clinical Supervisor* Number of Hours Per Week 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) Paraprofessional(s)

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 Reflect all the required staff on the above form. Please refer to the DBHDD Provider Manual Service Guidelines for Staffing Requirements. Site Address: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Medical Doctor /Psychiatrist* Number of Hours Per Week On-call Physician Physician s Assistant Nursing Staff: Clinical Nurse Specialist* Registered Nurse (RN)* Licensed Practical Nurse (LPN)* Other

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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Team Leader * Number of Hours Per Week 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) Site Address: 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. City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Team Leader * Number of Hours Per Week 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* Paraprofessional(s)* Other

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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Licensed Supervisor * Number of Hours Per 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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 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: City: County: State: Zip: AM PM By Appt. Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Program Physician* Number of Hours Per Week Clinical Director* (CACII, CADCII, MAC, LPC, LCSW, LMFT, CAS with Bachelor s degree) Physician s Assistant; Advanced Practice RN; Psychologist Registered Nurse (RN)* Licensed Professional Nurse (LPN) Licensed / Certified Practitioner* (LPC, LCSW, LMFT, CACII, CACI, CADCII, CADCI, MAC, CAS with Bachelor s degree) Associate Licensed Clinicians (LMSW, LAPC, LAMFT) Addiction Practitioner(s) (CACII, CADCII, CCADC, CAS) Paraprofessional(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 Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Program Leader * Number of Hours Per Week 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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Supervisor* (MAC, CACII, GCADCII,III) Number of Hours Per Week 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 (CACI, MAC, CACII, CADC, CCADC, GCADC II, GCADC III) Other

29 Site Address: 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. City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Whole Health and Wellness Coach* (CPS Whole Health Action Management (WHAM) Certified) Number of Hours Per Week Whole Health and Wellness Coach (CPS Whole Health Action Management (WHAM) Certified) Registered Nurse (RN)* Licensed Clinician (LCSW, LPC, LMFT) Certified Peer Specialist (Whole Health Action Management (WHAM) Certified) Other

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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Program Supervisor* Certified Psychiatric Rehabilitation Practitioner (CPRP) Number of Hours Per Week Clinical Supervisor* (LCSW, LPC, LMFT) Certified Psychiatric Rehabilitation Practitioner* Licensed Clinicians (LCSW, LPC, LMFT) Associate Licensed Clinicians (LMSW, LAPC, LAMFT) Certified Peer Specialist Addiction Practitioner (CACI, MAC, CACII, CADC, CCADC, GCADC II, GCADC III) Other

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: City: County: State: Zip: AM Monday Tuesday Wednesday Thursday Friday Saturday Sunday 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 Program Supervisor* Certified Psychiatric Rehabilitation Practitioner (CPRP) Number of Hours Per Week Employment Specialist* Certified Psychiatric Rehabilitation Practitioner Licensed Clinicians (LCSW, LPC, LMFT) Associate Licensed Clinicians (LMSW, LAPC, LAMFT) Certified Peer Specialist Paraprofessional Other

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: City: County: State: Zip: 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: City: County: State: Zip: 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 Meets the DDP definition of Behavior Specialist, Behavior Analyst, or Psychologist.

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 License number if applicable Certificate number if applicable Expiration date 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. Signature: Date: