ESBD_356715_1713468962989_PRIVATE PSYCHIATRIC BED Application.pdf

PRIVATE PSYCHIATRIC BED (PPB) SERVICES

OPEN ENROLLMENT APPLICATION

Application Instructions: Please be sure to answer every question. If the question does not apply to your organization, simply and clearly document “N/A.” Hill Country Mental Health and Developmental Disabilities Center reserves the right to not evaluate incomplete enrollment applications. False statements by any applicant may disqualify the application.

Applications must be sent to: Hill Country Mental Health and Developmental Disabilities Center

Contracts Department

819 Water Street, Suite 300

Kerrville, Texas 78028

-Applications may also be emailed to: purchasing@hillcountry.org

-Applications may not be faxed.

Questions regarding this application should be directed to Michael Beltran, michael8740@hillcountry.org, 830-792-7504, and purchasing@hillcountry.org.

Business Demographics

Legal Name: _____________________________________ ____ Tax ID# _______________

DBA: _______________________________________________________________________

Address: _____________________________________________________________________

City State Zip Code

Business Phone: _______________________ Fax #: _____________________________

Contact Person: ______________________Title: ___________________ Phone: ___________

Email: _______________________________________________________________________ mailto:purchasing@hillcountry.org mailto:michael8740@hillcountry.org mailto:purchasing@hillcountry.org

Indicate if you provide any of the following:

1. TTY/TTD (Hearing Impaired Services/Capabilities ___Yes ___No

2. American Sign Language ___Yes ___No

3. Handicap Accessible ___Yes ___No

4. Public Transportation Access ___Yes ___No

5. Bilingual Services ___Yes ___No

Services

A. Will the Hospital have qualified staff available to administer medications or to supervise individuals in the self-administration of medication? ________________________________

B. How many individuals can the Hospital serve? _____________________________________

C. How long do people currently wait to get into the Hospital’s services? __________________

D. Detail the specific population the Hospital would serve. Include ages and level of severity and concurrent diagnoses: _____________________________________________________

E. Are there any restrictions on who the Hospital will serve? ___________________________

If yes, please explain: ________________________________________________________

F. Describe the Hospital’s experience in providing emergency individual psychiatric stabilization services for individuals who present voluntarily or through the civil commitment process over the last five 5) years: ______________________________________________

G. Describe the Hospital’s ability to work with persons who are hearing impaired, persons who have limited language skills, and persons who speak a language other than English:

H. Describe the Hospital’s experience in working with persons with physical impairments and adaptive equipment: __________________________________________________________

Financial

A. Is the Hospital incorporated as “Profit,” “Not-for-Profit,” or “Other?” _______________ If

“Other,” please explain: _______________________________________________________

B. Does the Hospital have sufficient reserves or lines of credit to operate during the period between billing and receiving reimbursement from third party payors? __________________

If not, please explain: _________________________________________________________

C. Has the Hospital declared any type of bankruptcy in the prior seven (7) years? ____________

D. Is the Hospital currently under investigation, or has a license or accreditation revoked by any state/federal/local authority or licensure agency, within the last five (5) years? ____________

E. Has the Hospital had any judgements or settlements against it within the last ten (10) years?

____________ If yes, please explain: ____________________________________________

F. Has the Hospital been placed on “Vendor Hold” by any agency or government entity in the past three (3) years? ______ If yes, please explain: _________________________________

G. Is the Hospital currently held in abeyance or barred from the award of a federal or state contract? __________ If yes, has this occurred in the last five (5) years? ________________

Risk Assessment

A. Does anyone working for the Hospital providing direct care or in management have any felony convictions? ________ If yes, please explain: _______________________________

B. Has the Hospital or its employees had any validated client abuse, client neglect, or rights violations claims in the last three (3) years? _______ If yes, please explain in detail: ______

C. Does the Hospital currently have any malpractice claims pending or closed during the past five (5) years? _______ If yes, please supply the following information:

1. Letter from your attorney explaining the facts of the case.

2. Copies of the complaint and judgement.

3. Name of malpractice carrier that handled the claim and firm representing the carrier.

ASSURANCES DOCUMENT

Applicant assures the following:

1. That all attachments to the Application as distributed by HILL COUNTRY MHDD

CENTER Authority have been received.

2. The Applicant does not discriminate in its services or employment practices based on race, color, religion, sex, national origin, ethnicity, disability, veteran status, or age.

3. All cost and pricing information is reflected in the Application response document or attachments.

4. Applicant accepts the terms, conditions, criteria, and requirements set forth in the

Application.

5. Applicant accepts the HILL COUNTRY MHDD CENTER Authority’s right to cancel the

Application at any time prior to contract award.

6. Unless otherwise required by law, the information in the application submitted by the

Applicant has not been knowingly disclosed by the Applicant to any other Applicant prior to the notice of intent to award.

7. No claim will be made for payment to cover costs incurred in the preparation of the submission of the application or any other associated costs.

8. The individual signing this document and the contract is authorized to legally bind the

Applicant.

9. The address submitted by the Applicant to be used for all notices sent by the Local

Authority is current and correct.

Signature Authority for the Applicant Title of the Applicant Date