6-APPENDIX H Designation Certification and Licensure Attestation Form.pdf
PDF 191 KB Posted
- Solicitation number
- RFP 31-26-EM
- Issued by
- Bernalillo County, New Mexico
About this file
This is a Designation, Certification and Licensure Attestation Form prepared by Bernalillo County, New Mexico, on behalf of the County's Office of the County Manager and Behavioral Health Authority Division for the Intensive Case Management Services for Community Connections Supportive Housing Program. The form requires authorized signatories from bidding organizations to attest compliance with all applicable Federal, State, and local laws and regulations pertaining to administrative and clinical functions, including fraud and abuse prevention, HIPAA requirements, clinical licensure, staff credentialing, and health and safety standards. The attestation document requires organizations to identify their behavioral health provider designation category, service certifications, and staffing qualifications to establish eligibility and capability to provide the requested services.
Bidding organizations must document their organizational designation from categories including Behavioral Health Agency, Community Mental Health Center, Core Service Agency, Crisis Triage Center, Federally Qualified Health Clinic, and other qualifying designations. Organizations must also specify applicable service certifications such as Behavioral Health Management Services, Comprehensive Community Support Services, Intensive Outpatient, Assertive Community Treatment, and Residential Treatment Center services. The form requires identification of all licensed behavioral health professionals on staff or retained by the organization, including physicians, psychologists, social workers, counselors, and nurse practitioners, as well as paraprofessionals such as Certified Peer Workers, Peer Support Specialists, and Community Case Managers. The authorized signatory must execute the attestation under oath, confirming the accuracy and completeness of all declared information regarding organizational capacity and compliance capabilities.
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Text version
APPENDIX H
DESIGNATION, CERTIFICATION AND LICENSURE ATTESTATION
On this ________________day of _____________, ____________ I, ____________________, authorized signatory attest that _______________________, dba, ___________________ desires to do business with Bernalillo County and declare upon oath that our organization and staff will comply with applicable, Federal, State, and local laws and regulations pertaining to all administrative and clinical functions. This includes compliance with fraud, waste, and abuse, billing for services, reimbursement, HIPAA, information exchange, clinical licensure, certification, staff credentialing and screening laws, customer services, laws regulations and best practices, and other relevant health and safety requirements.
Our organization has the following Behavioral Health Provider designation is: (Please check all that apply)
☐Behavioral Health Agency (BHA) ☐Community mental health center (CMHC) ☐Core service agency (CSA) ☐Crisis Triage Center (CTC) ☐Federally qualified health clinic (FQHC) ☐Indian health services (IHS) hospital and clinic ☐PL 93-638 tribally operated hospitals and clinics ☐Children, youth and families department (CYFD) ☐Hospital and its outpatient facility ☐Other (Please check all that apply)
Our organization has the following service certifications: (Please check all that apply)
☐Behavioral Health Management Services (BMS) ☐Comprehensive Community Support Services (CCSS) ☐Intensive Outpatient (IOP) ☐Assertive Community Treatment (ACT) ☐Treatment Foster Care (TFC) ☐Residential Treatment Center (RTC) ☐Standard Outpatient Services (SOS) ☐Psychiatric Inpatient Services (PIS)
APPENDIX H
DESIGNATION, CERTIFICATION AND LICENSURE ATTESTATION
Our organization will staff or retain the following licensed behavior health professionals: (Please check all that apply and provide a list of all professionals and their license)
☐Physician (MD/DO) ☐Psychologist (Ph.D., Psy.D. or Ed.D.)
☐Social worker (LISW, LCSW,LMSW) ☐Licensed Professional Clinical Mental Counselor (LPCC) ☐Marriage and Family Therapist (LMFT) ☐Substance Abuse Counselor (LADAC/LSAA) ☐Licensed Mental Health Counselor (LMHC) ☐Nurse Practitioner (NP) ☐Clinical Nurse Specialist (CNS) ☐Certified Nurse Practitioner (CNP) ☐Professional Art Therapist (LPAT)
Our organization will staff or retain the following behavior health paraprofessionals: (Please check all that apply and provide a list of all paraprofessionals and their qualifications)
☐Certified Peer Worker (CPW) ☐Peer Specialist/Peer Support Worker (PSW) ☐Behavior Management Specialist (BMS) ☐Family Specialist/Family Peer Support Worker (FPSW) ☐Community Case Manager (CCM)
I attest that the preceding declaration is true, exact, and complete.
Authorized Signatory Signature and Title Date
| Behavioral Health Agency BHA: Off |
| Community mental health center CMHC: Off |
| Core service agency CSA: Off |
| Crisis Triage Center CTC: Off |
| Federally qualified health clinic FQHC: Off |
| Indian health services IHS hospital and clinic: Off |
| PL 93638 tribally operated hospitals and clinics: Off |
| Children youth and families department CYFD: Off |
| Hospital and its outpatient facility: Off |
| Other Please check all that apply: Off |
| Behavioral Health Management Services BMS: Off |
| Comprehensive Community Support Services CCSS: Off |
| Intensive Outpatient IOP: Off |
| Assertive Community Treatment ACT: Off |
| Treatment Foster Care TFC: Off |
| Residential Treatment Center RTC: Off |
| Standard Outpatient Services SOS: Off |
| Psychiatric Inpatient Services PIS: Off |
| Other Please check all that apply_2: Off |
| Physician MDDO: Off |
| Psychologist PhD PsyD or EdD: Off |
| Social worker LISW LCSWLMSW: Off |
| Licensed Professional Clinical Mental Counselor LPCC: Off |
| Marriage and Family Therapist LMFT: Off |
| Substance Abuse Counselor LADACLSAA: Off |
| Licensed Mental Health Counselor LMHC: Off |
| Nurse Practitioner NP: Off |
| Clinical Nurse Specialist CNS: Off |
| Certified Nurse Practitioner CNP: Off |
| Professional Art Therapist LPAT: Off |
| Other Please check all that apply_3: Off |
| Certified Peer Worker CPW: Off |
| Peer SpecialistPeer Support Worker PSW: Off |
| Behavior Management Specialist BMS: Off |
| Family SpecialistFamily Peer Support Worker FPSW: Off |
| Community Case Manager CCM: Off |
| Other Please check all that apply_4: Off |
| Date: |
| Day: |
| Month: |
| Year: |
| Name: |
| Company: |
| DBA: |
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