Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services Provider Enrollment Application Instructions Effective November 4, 2014, OMHSAS will only accept the current version of the Supplemental Service Provider Enrollment Application. If OMHSAS receives an outdated version of any enrollment application, the BH-MCO will be contacted to let them know the enrollment application will not be processed and will be shredded. Please Note the following important information: Applications will be scanned please do not staple; Please return pages 5, 7-as applicable, 9 through 17, 21 through 28, and 30-as applicable. Instruction pages should not be returned. Retroactive enrollment dates will only be considered within 30 days of receipt of application; Applications must be completed in black ink; Handwritten information must be legible; Applications must be completed by the provider representative who has the authority to submit applications on behalf of the provider; The individual who signs/dates the enrollment application/agreement must be the individual who has the authority to assure all information is true and accurate and will be accountable for adhering to Department/OMHSAS requirements. No corrections/changes should be made to the data contained in the provider enrollment application except by the provider representative responsible for completing the application. If a mistake is made or a change is needed, the provider representative must complete, initial and date the changed page; Modified provider enrollment applications will not be accepted; An enrollment application must be completed for each service location being enrolled; Out-of-State providers must submit proof of participation in their State s Medicaid Program The BH-MCO Attestation form must be completed in its entirety. 1. Supplemental Services: Check the type of supplemental service(s) for which you are applying. As noted, attach a copy of your License/Certificate of Compliance/Certificate of Licensure or your tailored Supplemental Service Description (SSD) and the OMHSAS SSRC approval letter, as applicable 2. Population to be Served: Check the appropriate box(es) to denote the age group(s) of the consumers you will be serving. 3. Action Requested: Check Initial Enrollment if you are: a. requesting enrollment as a new provider; b. expanding your enrollment to include a new or additional specialty type for a supplemental service; c. requesting to open a new service location (including a satellite location) Check Revalidation if this is to revalidate your enrollment. Please complete the entire application. Page 1 of 30 Updated 09/24/2014
Check Service Location Change if: a. you have an existing PROMISe service location and you have moved to a new physical location Check Fee Assignment if you are: a. Adding this provider to an existing provider group. Fee Assignment may only be made between like provider types. If enrollee is a Group, attach a copy of your Corporation Papers 4. Enrollee s Name: List the applicant s name (individual practitioner, facility or group) and date of birth and gender (if applicant is an individual). If operating under a fictitious business/doing-business-as (dba) name, attach copy of recorded/stamped fictitious business name statement/permit. 5. Tax Identification Information (TIN): Enter your Social Security Number. A copy of your Social Security card, W-2, or document generated by the Federal IRS containing your Social Security Number must accompany your application. Enter your Federal Tax ID Number (FEIN). A copy of the FEIN (TIN) label or document generated by the Federal IRS containing the name, and IRS number of the entity applying for enrollment must accompany this application. A W-9 form will not be accepted. Enter the legal name as shown on the FEIN, and the corresponding current address, telephone and fax numbers and contact information. (Note: Do not list tax information of entity to which payment will be made if said entity is not the enrollee.) *Individual practitioners enrolling with a FEIN, must still provide their SSN and SSN documentation. 6. National Provider Identifier (NPI) #: List your 10 digit NPI # and taxonomy(s). Include a copy of your NPPES confirmation letter verifying your NPI #. http://www.dpw.state.pa.us/provider/doingbusinesswithdpw/nationalprovideridentifiernpiinformation/index.htm 7. Business Type: Check the appropriate box for your business type (check one box only). Include corporation papers from the Department of State Corporation Bureau or a copy of your business partnership agreement, as applicable. 8. License: Enter the license number, issuing state, issue date, and expiration date, as applicable. A copy of your license is required for your application to be processed. 9. BH-MCO: Identify the BH-MCO with the network in which participation will occur. 10. Counties You Are Approved to Serve: List each county you are approved to serve. 11. Language: Indicate if any staff member can communicate with patients in another language in addition to English 12. Building Accessibility: Answer the questions relating to the Americans with Disabilities Act (ADA) Page 2 of 30 Updated 09/24/2014
13. Managing Employees or Agents: Indicate whether you retain any managing employees or agents. *If yes complete Attachment I 14. Confidential Information: The individual applying for enrollment OR the representative of the facility applying for enrollment must complete ALL confidential information questions. If Yes is answered to any of the questions, provide all applicable documentation as requested. Sign and date the form. 15. Physical Service Location: List the physical address where services will be provided. A Post Office Box is not a valid service location. 16. Mail To Information: Indicate the address of where you want correspondence to be mailed. (e.g. notification of enrollment) 17. Pay To Information: Indicate address of where payments will be sent. Payments will be initiated via the BH-MCO. 18. Home Office Information: Indicate the entity s headquarters address. 19. Sign and date the application, print your name and list your telephone number. The signature should be that of the individual applying for enrollment, or someone able to represent the facility applying for enrollment. Use black ink. Additional Required Forms: - Forward completed application to the Behavioral Health Managed Care Organization (BH-MCO) with which you are affiliated. Also include as applicable: One DPW Outpatient Provider Agreement with original signature and current date. Copy of Department of Drug and Alcohol Program (DDAP) Certificate of Licensure, Department of Public Welfare (DPW) Certificate of Compliance, Department of State (DOS) Licensure or a tailored service description, as applicable Copy of OMHSAS Field Office letter denoting SSRC approval of the tailored service description, as applicable. Verification of Tax ID name and number using the Department issued requirements. Individual practitioners enrolling with a FEIN, must still provide their SSN and SSN documentation Completed Ownership or Control Interest Forms, as applicable to the business type identified in question 7 on page 11 of the Behavioral Health Supplemental Services Provider Enrollment Application. Page 3 of 30 Updated 09/24/2014
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Commonwealth Of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services Behavioral Health Managed Care Organization Attestation Form **This form must be completed in its entirety** BH-MCO Name: Provider Name: Check one of the boxes below: has successfully completed the credentialing process as a Type of Supplemental Service provider. The population to be served is consistent with the requirements for this supplemental service. The County Contractor(s), where applicable, has/have approved the enrollment of this provider for the HealthChoices Supplemental Service listed above. List the applicable county(ies): is a (LPC, LMFT, etc) Group serving only as payee for services rendered, is the entity to which payment will be made, and is not a rendering provider. (Note: A group can be a provider type/provider specialty code combination 11/112 [MH Outpatient Practitioner] or 11/127 [D&A Outpatient Practitioner], and can serve as payee only for providers of a like provider type/provider specialty code combination) The requested effective date of enrollment into PROMISe is, BH-MCO Signature Printed Name Date Submittal Information Forward the completed BH-MCO Attestation Form, enrollment packet and all supporting documentation to: DPW/OMHSAS Business Partner Support Unit HealthChoices Enrollment 112 East Azalea Drive; 2 nd Floor Harrisburg, Pennsylvania 17110-3594 If the credentialed provider s enrollment application requires a Field Office Attestation Form, forward the completed BH-MCO Attestation Form, enrollment packet and all supporting documentation to the appropriate OMHSAS Field Office denoted below: OMHSAS OMHSAS OMHSAS OMHSAS Scranton Field Office Pittsburgh Field Office Southeast Field Office Harrisburg Field Office 100 Lackawanna Ave 301 Fifth Ave 1001 Sterigere St DGS Complex - Logan Bldg Room 321 Suite 480 Bldg 57; Room 105 120 E Azalea Dr 2 nd Floor Scranton, PA 18503 Pittsburgh, PA 15222 Norristown, PA 19401 Harrisburg, PA 17105 Page 5 of 30 Updated 09/24/2014
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Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services OMHSAS Field Office Attestation Form This form should only be completed for the provider types/provider specialties listed below. If the provider types/provider specialties are not listed below, do not complete this form. Provider Name: Check the appropriate box(es) below: I have reviewed and approved the attached tailored service description for this provider. The type of service is: BSU Diagnostic Assessment (Provider Type/Provider Specialty 11/110) Drug and Alcohol Intervention (Provider Type/Provider Specialty 11/184) Drug and Alcohol Level of Care Assessment (Provider Type/Provider Specialty 11/184) Drug and Alcohol Intensive Case Management (Provider Type/Provider Specialty 21/138) Drug and Alcohol Resource Coordination (Provider Type/Provider Specialty 21/138) Field Office Signature Printed Name Date Forward the completed enrollment packet, including the tailored service description and attestation forms to: DPW/OMHSAS Business Partner Support Unit HealthChoices Enrollment 112 East Azalea Drive; 2 nd Floor Harrisburg, Pennsylvania 17110-3594 Page 7 of 30 Updated 09/24/2014
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COMMONWEALTH OF PENNSYLVANIA OFFICE OF MENTAL HEALTH AND SUBSTANCE ABUSE SERVICES HealthChoices Behavioral Health Supplemental Services Provider Enrollment Application For OMHSAS Internal Use Only PROMISe ID / 1. Supplemental Services: Check the service(s) below for which you are applying. Attach a copy of the required document(s) as identified below. Residential and Housing Support Services DPW Certificate of Compliance Adult Residential Treatment Facility PT/PS 11/110 Adult Outpatient Treatment in an Alternative Setting PT/PS 11/110 Long Term Structured Residence PT/PS 11/110 Rehabilitative & Day Treatment Program Services DPW Certificate of Compliance Psychiatric Rehabilitation Site Based Mobile Clubhouse PT/PS 11/123 Outpatient - Drug & Alcohol DDAP Certificate of Licensure D&A Intensive Outpatient (IOP) PT/PS 11/128 D&A Outpatient in an Alternative Setting PT/PS 11/184 Drug & Alcohol Inpatient Non-Hospital DDAP Certificate of Licensure Drug-Free Halfway PT/PS 11/131 Detoxification PT/PS 11/132 Drug-Free Residential, Short Term PT/PS 11/133 Drug Free Residential, Long Term PT/PS 11/134 Drug & Alcohol Partial Hospitalization DDAP Certificate of Licensure Methadone Maintenance PT/PS 11/129 Drug-Free PT/PS 11/129 Drug and Alcohol Behavioral Health D&A Outpatient Practitioner DDAP Certificate of Licensure & DOS Licensure PT/PS 11/127 D&A Services Other SSD and FO SSRC approval letter PT/PS 11/184 D&A Intervention SSD & Field Office Attestation PT/PS 11/184 D&A Level of Care Assessment SSD & Field Office Attestation PT/PS 11/184 D&A Intensive Case Management SSD & Field Office Attestation PT/PS 21/138 D&A Resource Coordination SSD & Field Office Attestation PT/PS 21/138 Mental Health General BSU Diagnostic Assessment SSD & Field Office Attestation PT/PS 11/110 Community Treatment Teams SSD and FO SSRC approval letter PT/PS 11/111 Assertive Community Treatment (ACT) DPW Certificate of Compliance PT/PS 11/111 MH Outpatient Practitioner DOS Licensure PT/PS 11/112 Community MH Services, Other SSD and FO SSRC approval letter PT/PS 11/119 2. Population to be Served: Children (ages 0-12) Adolescents (13-17) Adults (18-64) Elderly (65 and up) Page 9 of 30 Updated 09/24/2014
3. Action Requested - Check Boxes That Apply: Initial Enrollment for Individual Facility Group Revalidation Individual Facility Group Service Location Change (include Service Location Change Form to close old location) Fee Assignment Add this provider to an existing provider group. You must complete the HealthChoices Behavioral Health Supplemental Services Fee Assignment Form. 4. Enter Name of Enrollee: Facility Name: Or Last Name: First: Middle: : / / Ex: (yyyy/mm/dd) Gender: Male Female 5. Tax Identification Information Social Security Number: - - *A copy of the document generated by the IRS that includes your name and SSN must accompany this application. OR Federal Tax ID Number: - *A copy of the document generated by the Federal IRS with the name and IRS number must accompany this application. **Individual practitioners enrolling with a FEIN, must still provide their SSN and SSN documentation** Legal Name (must be same as denoted on tax ID): Address: City: County: State: Zip Code (9 digit) Telephone: ( ) - Fax: ( ) - Contact Name/Title: Contact e-mail: 6. National Provider Identifier (NPI) #: *A copy of the NPPES confirmation letter must be attached Taxonomy(s): (10 digits) http://www.dpw.state.pa.us/provider/doingbusinesswithdpw/nationalprovideridentifiernpiinformation/index.htm Page 10 of 30 Updated 09/24/2014
7. Business Type: Corporation Not-for-Profit Government Owned Partnership Estate/Trust Sole Proprietorship (Include corporation papers or business partnership agreement, as applicable) 8. License #: Issuing State: Issue Date: / / Expiration Date: / / *A copy of your license is required for your application to be processed. 9. Behavioral Health Managed Care Organization (BH-MCO): Identify the BH-MCO with the network in which participation will occur. 10. Counties You Are Approved to Serve: 11. In addition to English, do you or your staff communicate with patients in another language: Yes No If yes, list language(s): 12. a) Does the office have exterior or interior steps leading to the main entrance doorway? Yes No Exterior Interior b) If the answer to (a) is yes, does the office have a permanent or portable wheelchair ramp? Yes No Permanent Portable c) If the answer to (a) is yes, is there an alternate entrance that has no exterior or interior steps or has a wheelchair ramp? Yes No No exterior steps No interior steps Permanent ramp Portable ramp d) Does the office have an official exemption from the U.S. Department of Justice excusing compliance with Title III of the Americans with Disabilities ACT (ADA)? Yes No *If yes, attach a copy of the exemption to your application. 13. Does the provider retain any managing employees or agents? Yes * No If yes, please complete Attachment I (Managing Employee or Agent Disclosure Form) on the next page. Page 11 of 30 Updated 09/24/2014
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Attachment I Managing Employee or Agent Disclosure Form A. Please provide the name, home address, social security number, and date of birth of any person who is an agent or managing employee of the provider. Is the following individual a: Managing employee or an Agent Is the following individual a: Managing employee or an Agent B. Please provide the name and description of offense of any person who is an agent or managing employee and has been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program. Name: (First) (Middle) (Last) Description of offense Name: (First) (Middle) (Last) Description of offense Name: (First) (Middle) (Last) Description of offense Page 13 of 30 Updated 09/24/2014
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14. CONFIDENTIAL INFORMATION Have you, any agent, or managing employee ever: Been terminated, excluded, precluded, suspended, debarred from or had their participation in any federal or state health care program limited in any way, including voluntary withdrawal from a program for an agreed to definite or indefinite period of time? Yes No Been the subject of a disciplinary proceeding by any licensing or certifying agency, had his/her license limited in any way, or surrendered a license in anticipation of or after the commencement of a formal disciplinary proceeding before a licensing or certifying authority (e.g., license revocations, suspensions, or other loss of license or any limitation on the right to apply for or renew license or surrender of a license related to a formal disciplinary proceeding)? Yes No Had a controlled drug license withdrawn? Yes No Been convicted of a criminal offense related to Medicare or Medicaid; practice of the provider s profession; unlawful manufacture, distribution, prescription or dispensing of a controlled substance; or interference with or obstruction of any investigation? Yes No In connection with the delivery of a health care item or service, been convicted of a criminal offense relating to neglect or abuse of patients or fraud, theft, embezzlement, breach of fiduciary responsibility, or other financial misconduct? Yes No If you answered Yes to any of the questions above, you must provide a detailed explanation (on a separate piece of paper) and submit three (3) statements from professional associates or peer review bodies giving factual evidence of why they believe the violation(s) will not be repeated, and attach it to your application. Include the following information as applicable to the situation: 1. Name and title of individual 8. Disposition/State 2. Name of federal or state health care program 9. Date license was surrendered 3. Name of licensing/certifying agency taking the action 10. Name of court 4. Date of action 11. Date of conviction 5. Type of action taken 12. Offense(s) convicted of 6. Length of action 13. Sentence(s) 7. Basis for action 14. Categorization of offense (e.g., felony, misdemeanor) This section requires the original signature of the individual applying for enrollment. Title Original Signature Printed Name Date Page 15 of 30 Updated 09/24/2014
15. Physical Service Location: Street (Note: List physical street address. A PO Box is not acceptable.) City State Zip (9 digit) County ( ) - Phone E-mail Is this address an active Rural Health Clinic or FQHC? Yes or No 16. Mail To Information: Street City State Zip (9 digit) County Contact Name/Title ( ) - Phone E-mail 17. Pay To Information: Street City State Zip (9 digit) County Contact Name/Title ( ) - Phone E-mail 18. Home Office Information: Street City State Zip (9 digit) County Contact Name/Title ( ) - Phone E-mail 19. ( ) Provider s Signature Printed Name Telephone Date Page 16 of 30 Updated 09/24/2014
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services PROVIDER AGREEMENT FOR OUTPATIENT PROVIDERS 1. This is to certify that agrees to participate in the Pennsylvania Medical Assistance Program on the following terms: 2. The provider shall comply with all applicable State and Federal laws, regulations, and policies which pertain to participation in the Pennsylvania Medical Assistance Program. 3. Specifically, and without limitations, the provider shall: a. Keep any records necessary to disclose the extent of services the provider furnishes to recipients; b. Upon request, furnish to the Department of Public Welfare, the United States Department of Health and Human Services, the Medicaid Fraud Control Unit, any other authorized governmental agencies and the designee of any of the foregoing, any information maintained under paragraph (a) above and any information regarding payments claimed by the provider for furnishing services under the Pennsylvania Medical Assistance Program; and c. Comply with the disclosure requirements specified in 42 CFR, Part 455, Subpart B (relating to Disclosure of Information by Providers and Fiscal Agents), or any amendments thereto. 4. This agreement shall continue in effect unless and until it is terminated by either the provider or the Department. Either the provider or the Department may terminate this agreement, without cause, upon thirty days prior written notice to the other. The provider s participation in the Pennsylvania Medical Assistance Program may also be terminated by the Department, with cause, as set forth in applicable Federal and State laws and regulations. By: Original Signature of Provider (No Stamp) Printed Name of Provider **Date must coincide with the date of the application. Date Page 17 of 30 Updated 09/24/2014
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Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services Pennsylvania Provider Reimbursement and Operations Management Information System electronic (PROMISe ) Medicaid Management Information System (MMIS) is a HIPAA compliant database. All information entered is maintained according to Federal HIPAA and privacy regulations. For your reference, please visit the link below for Medical Assistance Bulletin (MAB) 99-11-05. This bulletin applies to all providers enrolling in the MA Program. http://www.dpw.state.pa.us/publications/bulletinsearch/bulletinselected/index.htm?bn=99-11-05 Provider Disclosure Statement Definitions The definitions below are designed to clarify certain questions on the following forms. If you cannot report all of the necessary information in a designated section of the form because of space limitations, please print and attach additional sheets. Definitions Agent means any person who has been delegated the authority to obligate or act on behalf of a provider. Disclosing entity means a Medicaid provider (other than an individual practitioner), or a fiscal agent. Any entity that does not participate in Medicaid, but is required to disclose certain ownership and control information because of participation in any of the programs established under title V, XVIII, or XX of the Act means: a. Any hospital, skilled nursing facility, home health agency, independent clinical laboratory, renal disease facility, rural health clinic, or health maintenance organization that participates in Medicare (title XVIII); b. Any Medicare intermediary or carrier; and c. Any entity (other than an individual practitioner or group of practitioners) that furnishes, or arranges for the furnishing of, health-related services for which it claims payment under any plan or program established under title V or title XX of the Act. Fiscal agent means a contractor that processes or pays vendor claims on behalf of the Medicaid agency. Group of practitioners means two or more health care practitioners who practice their profession at a common location (whether or not they share common facilities, common supporting staff, or common equipment). Indirect ownership interest means an ownership interest in an entity that has an ownership interest in the disclosing entity. This term includes an ownership interest in any entity that has an indirect ownership interest in the disclosing entity. Individual practitioner means a physician or other person licensed or certified under State Law to practice his or her profession. Managing employee means a general manager, business manager, administrator, director, or other individual who exercises operational or managerial control over, or who directly or indirectly conducts the day to day operation of an institution, organization, or agency. Ownership interest means the possession of equity in the capital, the stock, or the profits of the disclosing entity. Page 19 of 30 Updated 09/24/2014
Person with an ownership or control interest means a person or corporation that: a. Has an ownership interest totaling 5 percent or more in a disclosing entity; b. Has an indirect ownership interest equal to 5 percent or more in a disclosing entity; c. Has a combination of direct and indirect ownership interest equal to 5 percent or more in a disclosing entity; d. Owns an interest of 5 percent or more in any mortgage, deed of trust, note, or other obligation secured by the disclosing entity if that interest equals at least 5 percent of the value of the property or assets of the disclosing entity; e. An officer or director of a disclosing entity that is organized as a corporation; or f. Is a partner in the disclosing entity that is organized as a partnership Significant business transaction means any business transaction or series of transactions that, during any one fiscal year, exceed the lesser of $25,000 and 5 percent of a provider s total operating expenses. Subcontractor means: a. An individual, agency, or organization to which a disclosing entity has contracted or delegated some of its management functions or responsibilities of providing medical care to its patients; or b. An individual, agency, or organization with which a fiscal agent has entered into a contract, agreement, purchase order, or lease (or leases of real property) to obtain space, supplies, equipment, or services provided under the Medicaid agreement. Supplier means an individual, agency, or organization from which a provider purchases goods and services used in carrying out its responsibilities under Medicaid (e.g., a commercial laundry, a manufacturer or hospital beds, or a pharmaceutical firm). Wholly owned supplier means a supplier whose total ownership interest is held by a provider or by a person, persons, or other entity with an ownership or control interest in a provider. Government Owned means property interests that are vested in the state rather than an individual or private entity. Page 20 of 30 Updated 09/24/2014
If you are a non-profit organization, please skip this section and complete Attachment II. **This is the contact name and phone number we will use if we have any questions about this document. Contact Name: Provider Name: Phone: e-mail Address: Ownership or Control Interest Note: Ownership and Controlling Interest information is required in accordance with Federal Regulation 42 CFR, Part 455, published July 17, 1979, and expanded through additional subparts on February 2, 2011, through the Provider Enrollment and Screening provisions of the Affordable Care Act. Please enter the full name and home address of partners, stockholders, corporate owners, or officers that have at least 5% direct or indirect ownership interest. Attach additional sheets, if necessary. Complete below for Individuals: **ATTACH ADDITIONAL SHEETS IF NECESSARY** Page 21 of 30 Updated 09/24/2014
Complete below for Corporate Entities: Ownership or Control Interest (continued) The address for each corporate entity must include: primary business address, every business location, and P.O. Box address Attach additional sheets, if necessary. - Name of Corporation FEIN/Tax ID Number Street Address PO Box - Name of Corporation FEIN/Tax ID Number Street Address PO Box - Name of Corporation FEIN/Tax ID Number Street Address PO Box - Name of Corporation FEIN/Tax ID Number Street Address PO Box **ATTACH ADDITIONAL SHEETS IF NECESSARY** Page 22 of 30 Updated 09/24/2014
Ownership or Control Interest (continued) Please enter the full name and home address of each person with an ownership or controlling interest in any subcontractor in which the disclosing entity has a direct or indirect ownership interest of 5% or more. Attach additional sheets, if necessary. Has this individual been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program? Yes* No * If Yes, please attach details. Has this individual been convicted of a criminal offense related to Medicare or Medicaid, or a state health care program? Yes* No * If Yes, please attach details. **ATTACH ADDITIONAL SHEETS IF NECESSARY** Are any of the aforementioned persons related to each other as a spouse, parent, child, or sibling? If so, please list the names of the individuals and how they are related. Names: Relationship: Names: Relationship: Names: Relationship: Page 23 of 30 Updated 09/24/2014
Ownership or Control Interest (continued) Do you or any of the aforementioned individuals have a controlling interest in, or own other providers of services? Yes* No *If Yes, list the name and address of each provider. Provider Name: Street Address Identify the name of individual(s) with ownership or controlling interest Provider Name: Street Address Identify the name of individual(s) with ownership or controlling interest Provider Name: Street Address Identify the name of individual(s) with ownership or controlling interest Provider Name: Street Address Identify the name of individual(s) with ownership or controlling interest **ATTACH ADDITIONAL SHEETS IF NECESSARY** Page 24 of 30 Updated 09/24/2014
Has the provider had any significant business transactions with any wholly owned supplier or with any subcontractor during the preceding five year period? Yes* No *If Yes, give the information below for each wholly owned supplier or subcontractor. Attach additional sheets, if necessary Street Address Street Address Page 25 of 30 Updated 09/24/2014
Non-Profit Disclosure Attachment II Please add anyone who has a controlling interest or is a board member President: Vice President: Secretary: Treasurer: Page 26 of 30 Updated 09/24/2014
Attachment II continued Other: - - **ATTACH ADDITIONAL SHEETS IF NECESSARY** Page 27 of 30 Updated 09/24/2014
Government Owned Entities Attachment III A. Please provide the name, home address, social security number, and date of birth of County Commissioners managing the Government owned facility listed on the application. Page 28 of 30 Updated 09/24/2014
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services Fee Assignment Form for Group Members Instructions Date: enter today s date Group 13-Digit Provider ID: enter the 13-digit provider ID of the group you want to assign payment to Group Name: enter the group name Contact Name: enter a contact name that can be contacted for any questions related to this enrollment Contact Phone: enter the phone number of the above contact person This form can be used for up to five individual practitioners assigning payment to the same group. Each individual practitioner assigning payment must enter their printed name, 13-digit provider id number and effective date to be used for assigning payment to the group. The individual practitioner must also sign the form. Stamped signatures are not acceptable. Page 29 of 30 Updated 09/24/2014
Commonwealth of Pennsylvania Office of Mental Health and Substance Abuse Services HealthChoices Behavioral Health Supplemental Services Fee Assignment Form for Group Members Date: Group 13-Digit Provider ID: Group Name: _ Contact Name: Contact Phone: ( ) - Note: By signing, I am agreeing to assign my fees to the Group and Service Location, listed above. 1. Printed Name of Individual Provider Assigning Payment Original Signature of Individual Provider Assigning Payments (No Stamp) 13 Digit Individual Provider Number Effective Date 2. Printed Name of Individual Provider Assigning Payment Original Signature of Individual Provider Assigning Payments (No Stamp) 13 Digit Individual Provider Number Effective Date 3. Printed Name of Individual Provider Assigning Payment Original Signature of Individual Provider Assigning Payments (No Stamp) 13 Digit Individual Provider Number Effective Date 4. Printed Name of Individual Provider Assigning Payment Original Signature of Individual Provider Assigning Payments (No Stamp) 13 Digit Individual Provider Number Effective Date 5. Printed Name of Individual Provider Assigning Payment Original Signature of Individual Provider Assigning Payments (No Stamp) 13 Digit Individual Provider Number Effective Date Page 30 of 30 Updated 09/24/2014