2-Item 26 Provider Service Site Information rev0051724.docx
DOCX document 17 KB Posted
- Solicitation number
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- Milwaukee County, Mattoon Village, Wisconsin
About this file
The document is a Provider Service Site Information form for Item #26, associated with the Milwaukee County Behavioral Health Services (BHS) Comprehensive Community Services (CCS) Ancillary Services Open Enrollment Expression of Interest (EOI). The EOI seeks to expand the CCS Network by identifying community providers interested in offering ancillary services for youth and/or adults in 2026, with specific services open to both new and current providers looking to expand their service offerings.
The form requires detailed site-specific information, including agency name, site location, contact details, service capabilities, and operational hours. Providers must indicate the types of programs offered, such as services for men, women, families, pregnant women, persons in the criminal justice system, and individuals with developmental or physical disabilities. The form also captures the site's daily service capacity, current service levels, accessibility, and emergency contact information. Providers must certify the accuracy of the submitted information as of the proposal submission date, with the certification to be included in the cover letter.
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Other files
| File | Type | Posted |
|---|---|---|
| 10-Submission Instructions - DHHS-BHS-EOI-CCS Ancillary.docx | DOCX document | |
| 11-Preliminary QA CCS Ancillary EOI 080325.pdf | ||
| 12-Final QA CCS Ancillary EOI 080725.pdf | ||
| 6-Item TBE Targeted Business Enterprise Certification rev042525.docx | DOCX document | |
| 8-Expression of Interest Open Enrollment CCS Ancillary.docx | DOCX document | |
| 9-Item 1 Cover Letter EOI rev070124.docx | DOCX document | |
| 1-Item 16 Additional Disclosures rev051724.docx | DOCX document | |
| 3-ITEM 26a Agency Site Info Rev 1.xlsx | XLSX spreadsheet | |
| 4-Item DCPI Designation of Confidential and Proprietary Information rev051724.docx | DOCX document | |
| 5-Quick Reference Service Type List General 5.19.2025.xlsx | XLSX spreadsheet | |
| 7-Item EOI Open Enrollment Questionnaire.docx | DOCX document |
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Text version
PROVIDER SERVICE SITE INFORMATION ITEM #26
Provide a separate sheet for EACH site location where services are provided.
| Agency Name: |
| Site Name: |
| Site Address: |
| City/State/Zip: |
| Site Contact Person: |
| Title: |
| Phone: |
| Email: |
Fax:
Describe differences in programs or services available at this site:
Total number of unduplicated consumers you are presently able to serve on any one day: ________
Total number of unduplicated consumers you are currently serving: ____________
Please check if your agency provides the following at this site:
____Programs for men ____Programs for women ____Programs for men & women
____Services for pregnant women
____Services for families with children ____Childcare provided
____Services for Persons Involved in the Criminal Justice System
____Services for the Developmentally Disabled ____Services for the Physically Disabled
____Services for persons with co-occurring mental health and substance use disorders
Wheelchair accessible
Please provide the Hours of operation for specific program and for all programs at this site
| Hours of Operation (Specific program) |
| Hours of Operation (All programs) |
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Emergency contact available 24 hours (Y/N):
Emergency contact number:
Agency owns this Service Site (Y/N):
Agency leases this Service Site (Y/N):
Item 26 Service Site Certification: I certify that the PROVIDER SERVICE SITE INFORMATION is correct as of the date of proposal submission.
**Certification included in cover letter**
File details come from the government source that posted it. Updated .