3-ITEM 26a Agency Site Info Rev 1.xlsx
XLSX spreadsheet 45 KB Posted
- Solicitation number
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- Milwaukee County, Mattoon Village, Wisconsin
About this file
The document is an Agency Information Form for Milwaukee County Department of Health and Human Services, specifically for their Behavioral Health Services (BHS) division, covering multiple service areas including CARS, Wrap, CYFS, ADS, and HS/MS. The form is part of an Expression of Interest (EOI) for Comprehensive Community Services (CCS) Ancillary Services, seeking new and expanded service providers for youth and adult programs in 2026. The EOI is open to community agencies and organizations interested in providing services across various divisions, with a focus on expanding the CCS Network in targeted service areas.
The form provides comprehensive details for potential service providers, requiring extensive information about agency structure, site locations, licensing, client demographics, and service capabilities. Key requirements include documenting site-specific details such as type of site, funding divisions, services provided, client types, multilingual capabilities, and operational hours. Providers must specify their certifications, licenses, and service offerings for each division (BHS, CARS, Wrap, CYFS, ADS, HS, MS), with particular attention to client categories including developmental disabilities, mental health, substance abuse, homeless populations, and juvenile justice-involved individuals. The form emphasizes the agency's responsibility to maintain current personnel licenses and certifications.
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Text version
Instruction
| Instructions |
| Need one form per Agency per network or Service Area. If you are filling the RFI for Wrap, CARS and ADS you will need fill three forms (one each for Wrap , CARS and ADS) |
| you can enter details in Grey area only. |
Tab Description
| Agency info | Please enter all agency demographic information in this Tab | |
| Entity Type | Select one of the entity type listed, if you think you are missing a type you can go on Tab List and add under Entity type listing in grey area and then come back to form and select that item. | |
| Contract Signor Name | ||
| Please fill the information about the individual who will sign the contract. Please repeat the same name etc. if CEO/Executive director will sign it. | ||
| Contact (Contract Notification/Communication) | ||
| Please fill the information about the individual who will receive the Contract related notification or communication (this may be same person who is signing or CEO/Executive Director ). | ||
| Contact Name ( Add-Delete and CBC) | Please fill the information about the individual who will be contact for all add delete and CBC related queries. | |
| Contact Name ( Avatar login requests) | If your Agency do not require Synthesis access, leave blank. Otherwise Please fill the information about the individual who will be contact for all Synthesis login or change requests (all requests or changes will be processed through this contact). | |
| Contact Name (Synthesis Login requests) | If your Agency do not require Avatar access, leave blank. Otherwise Please fill the information about the individual who will be contact for all Avatar login requests (all requests or changes will be processed through this contact). | |
| Contact Name (Billing) | Please fill information about the individual who will be contact for all Billing related questions. |
Site Info Please enter each site on a separate line, even if you have just one office you need to fill the details in this form
| Please fill all site related to the network or Division you are submitting data for. | ||
| A sample is provided to show how the form will be filled | ||
| item 13 Type of Site | It give you an option to select from the list, however you do not find you site type listed please for the Tab "List" and add the Type under Site Type in Grey area and come back to site info and select that item/entry. | |
| CBRF/AFH etc. | If your agency do not have a state provided rate and you have been asked to provide a rate sheet please enter X in front of all sites where you are providing the rate sheet(s). | |
| Ver 5/24 |
Agency Info Milwaukee County Department of Health and Human Services
Agency Information Form
| Division (Check all that apply) | |||||||
| BHS | CARS | Wrap | CYFS | ADS | HS | MS | Entity Type (Select one) |
Kalia, Sumanish: If missing a entity type please enter in grey area on tab list under entity list
| Agency Name* | |||
| Mailing Address | |||
| City | State | Zip | |
| Phone | Fax | ||
| Fed ID | NPI |
| CEO/Executive Director Name | ||
| Title | Phone |
Contract Signor Name
Title Email Phone
Contact (Contract Notification/Communication)
Title Email Phone
| Contact Name ( Add-Delete and CBC) | ||
| Title | Phone |
| Contact Name ( Avatar login requests) | ||
| Title | Phone |
| Contact Name (Synthesis Login requests) | ||
| Title | Phone |
| Contact Name (Billing) | ||
| Title | Phone |
| *If Subsidiary, Please provide following info for Parent | |||
| Agency Name | |||
| Mailing Address | |||
| City | State | Zip | |
| Phone | Fax | ||
| Fed ID | NPI |
| CEO/Executive Director Name | ||
| Title | Phone |
Please note that your agency is responsible for ensuring that all individual licenses and certifications are kept current and active in personnel records. By signing below, you attest that all applicable personnel records contain current licensure. If there are any licensure that become expired/revoked, it is your agency’s responsibility to send notification of the change in status.
Authorized Signature# (please type your first and last name)
| Title | Date |
| #By typing your name above constitute a legal signature and you attest to above statement and information submitted with this form including Site info to be accurate. |
IMPORTANT : Please Fill the site info form even if the company and site are the same
Site Info
| Site Information Form | |||||||
| Agency Name | |||||||
| Type of Site | Funding Division & Services | List all licenses applicable to Site | Type of Property | Hours/Time of Operation | Multi Lingual staff | Client Type ( enter x for all applicable) |
Kalia, Sumanish: A-Adult, C-Child M-Male, F-Female
Client Category ( enter x for all applicable) Kalia, Sumanish: DD-Developmental disable, PD- Physically Disabled SED- Serious Emotional Disturbance
| H-Homeless , J-Person involved with Juvenile Justice system, MH/AODA- Co-occurring Mental Health and Substance abuse | CBRF/AFH etc. | ||||||||||||||||||||||||||||||||||||||
| # | Site Name | Site Address | Suite or Room # | City | State | Zip | Site Contact Person Name | Title | Phone | Fax | Select one or enter in Grey area on Tab List | BHS | CARS | Wrap | CYFS | ADS | HS | MS | Programs/Services provided at location | Certification/ License Type | Expiration Date | Certification/ License Type | Expiration Date | Certification/ License Type | Expiration Date | Certification/ License Type | Expiration Date | Type | If rented Lease expiration date | Normal work hours | Normal work days | open weekends | 24/7 | Wheelchair Accessible | Spanish | Hmong | Other |
Kalia, Sumanish: R -Russian, G-German, P- Polish, F-French, C-Chinese, I-Italian, P-Hindi/Punjabi
| A | C | M | F | DD | PD | SED | MH/AODA | H | J | other | Rate Sheet attached | |
| List all services being provided for each division under respective division column. Leave blank if no services being provided for a division. |
Kalia, Sumanish: TCM, CCS, CSP, Shelter, AODA, care coordination, B2T, Mentoring, Therapy, aftercare, respite, foster home, etc.
Kalia, Sumanish: A-Adult, C-Child M-Male, F-Female
Kalia, Sumanish: R -Russian, G-German, P- Polish, F-French, C-Chinese, I-Italian, P-Hindi/Punjabi
Kalia, Sumanish: DD-Developmental disable, PD- Physically Disabled SED- Serious Emotional Disturbance
| H-Homeless , J-Person involved with Juvenile Justice system, MH/AODA- Co-occurring Mental Health and Substance abuse | Leave blank | O-owned, R-Rented | Date | Ex.: '9-5, 24 hr. | M-F or 7 days | enter X | enter X | enter X | enter X | enter X | enter all that apply | enter Description | Enter X | ||||||||||||||||||||||||||||||||||||
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| sample | 15th St Clinic (North) | 123 15th Street | 202 | Milwaukee | WI | 53999 | John, Doe | Manager | abd@abc.com | (414) 999-1234 | (414) 999-1235 | CBRF | TCM, CSP | AODA Residential | Respite | Shelter, Supportive housing | CBRF | 9/12/22 | AODA Clinic | 9/18/19 | R | 8/22/20 | 8-4:30 | M-S | X | X | X | R,G | X | X | X | X | X | X | |||||||||||||||
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mailto:abd@abc.com List Entity Type Type of Site
| C Corp | AFH |
| Govermental/Municipal | CBRF |
| Individual | Clinic |
| LLC | CRC |
| Non Profit | Foster Home |
| Partnership | GroupHome |
| S Corp | RCC |
| Sole Proprietorship | Shelter |
| Supp. Apt |
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