EP_Program_Attestation_Form.docx
DOCX document 16 KB Posted
- Attached to
- Early Psychosis Coordinated Specialty Care Program Staff Enhancement and Evidence Based MA RFA
- Solicitation number
- BD-23-1022-DMH08-8210C-87233
- Issued by
- Massachusetts
About this file
This document is a Statement of Attestation for the Massachusetts Department of Mental Health's (DMH) Early Psychosis Coordinated Specialty Care (EP CSC) Program grantees. As a DMH EP CSC Program grantee, the applicant organization agrees to requirements such as participating in multi-disciplinary team meetings, staff supervision, Learning Collaborative activities, administering and reporting on the EP CSC Assessment Battery, and pursuing third-party payment options to sustain the program. The applicant organization must sign this statement to confirm their understanding and agreement with these requirements.
The related state and local contract opportunity is the DMH's Request for Applications to establish a pool of existing or planned EP CSC Programs to which it can award grants to enhance staffing or assist with the implementation of Evidence Based Practices. This opportunity is open to applicants in the state of Massachusetts.
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Massachusetts Department of Mental Health EP CSC Program Statement of Attestation
As a DMH EP CSC Program grantee, [insert applicant organization name] will adhere to the following requirements:
EP CSC Program team members will participate in regularly scheduled EP CSC Program multi-disciplinary team meetings and
EP CSC Program team members will participate in regularly scheduled staff supervision specific to EP CSC services.
EP CSC Program team members will participate in all required Learning Collaborative activities.
The EP CSC Program will administer, use, and report EP CSC Assessment Battery data to inform treatment planning, continuous quality improvement, and grant monitoring reports for DMH.
The EP CSC Program and Applicant Organization will pursue and maximize 3rd party payment options and any revenue generated by grant funded positions will be used to offset the cost of those positions.
The EP CSC Program and Applicant Organization will develop plans to sustain EP CSC program activities, including third party reimbursement.
Statement of Attestation By signing the Statement of Attestation, I have signing authority on behalf of my organization and understand the requirements for DMH EP CSC Program grantees.
Organization Name:
NPI or Tax ID:
Print Name:
Title:
Physical Address:
Phone:
Email:
Signature___________________________________________ Date ___________
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