CDR RFA Attachment A Application for Participation.docx

COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

MASSHEALTH PROGRAM CDR HOSPITAL RFA

ATTACHMENT A: Application for Participation

INSTRUCTIONS

Fully complete and sign this application (if applying for multiple hospitals, provide one copy for each Hospital) and submit it, along with all other required documentation, in accordance with Section 4 of the RFA.

GENERAL INFORMATION:

1. Name of Licensee: _______________________________________________________

2. Address of Licensee: _____________________________________________________

3. Name of Hospital: _______________________________________________________

4. Address of Hospital: _____________________________________________________

ADMINISTRATIVE AND CLINICAL QUALIFICATIONS

1. Is the applicant Hospital located in Massachusetts?

yes ☐ no ☐

2. Is the applicant Hospital Medicare-certified?

yes ☐ no ☐

3. Is the applicant Hospital licensed by the Massachusetts Department of Public Health (DPH)?

yes ☐ no ☐

4. Total number of DPH Licensed Beds: ___________________________________

5. Is the applicant Hospital licensed with a pediatric specialty?

INPATIENT SITE INFORMATION: (Hospitals with more than one Inpatient Site must provide the following information for each Inpatient Site. If needed, attach additional sheet[s].)

1. Address of Hospital Inpatient Site: _____________________________________

2. Provider Number: ____________________ NPI:__________________________

3. Number of licensed beds at the above Inpatient Site location: ________________

4. Designation of beds at the above Inpatient Site location:

Medical/Surgical

Chronic Care

Rehabilitation

SNF/NF

Other (describe)

OUTPATIENT SITE INFORMATION: (Hospitals with more than one Outpatient Site must provide the following information for each Outpatient Site. If needed, attach additional sheet[s].)

1. Address of Hospital Outpatient Site: ____________________________________

2. Provider Number:_____________________ NPI:__________________________

ACKNOWLEDGEMENT

This RFA requires that all information required by the most recent MassHealth provider application(s) of the applicant Hospital, as well as all required supporting documentation, be current, complete, and accurate. In response to this item, the applicant must attach all additional information and/or documentation, which is necessary to update, complete or correct such application(s). In addition, this RFA requires that once an applicant executes an agreement with EOHHS, it has a continuing obligation pursuant to that agreement to submit promptly all additional information and/or documentation to reflect any changes to previously submitted documentation and/or information pursuant to this RFA.

I, _____________________, hereby certify that the information submitted in response to the Chronic Disease and Rehabilitation Hospital Request for Applications, including this Application for Participation in Appendix A, is current, complete and accurate.

THIS APPLICATION IS SIGNED UNDER THE PAINS AND PENALTY OF PERJURY.

Signature of Person Authorized to Execute Contract Date

Name and Title (Please Print)