ESBD_395620_1739388397324_OPEN ENROLLMENT_IDD_2.4.25.docx

OPEN ENROLLEMENT

REQUEST FOR APPLICATION (RFA)

Intellectual and Developmental Disabilities (IDD) Services

February 2025

Denton County MHMR Center Attn: Natalee Galvan contractsubmission@dentonmhmr.org

REQUEST FOR PROPOSALS FOR

STRATEGIC PLANNING SERVICES

Table of Contents

Section Title Page

Description of Denton County MHMR ……………………………………………….………………...3

Description of Services………………………………………………………………………………………….4

General Information 5

Conditions 6

Selection of Successful Proposer 10

Performance Standards and Compliance 11

Proposal Instructions and Guidelines 12

Attachments Attachment A – INTELLECTUAL AND DEVELOPMENTAL DISABILITIES (IDD) PRIORITY POPULATION

Attachment B – SERVICE DEFINITIONS AND RATES

Attachment C – FORM-B CREDENTIALING AND ATTESTATION FOR NON-LICENSED PROVIDERS

Attachment D – ATTESTATION

Attachment E – GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION

Attachment F – ASSURANCES DOCUMENT

Attachment G – CERTIFICATION REGARDING LOBBYING, GRANTS, LOANS, & COOPERATIVE AGREEMENTS

Attachment H – EXECUTIVE LEADERSHIP TEAM

Attachment I – BH CRIMINAL BACKGROUND CHECK FORM

INTRODUCTION

The Denton County MHMR Center (hereinafter referred to as “The Center”), Texas Department of Aging and Disability Services (DADS) has authorized Denton County MHMR, as the Local Authority, to assemble a network of service providers to provide intellectual and developmental disabilities (IDD) services to the Priority Population of persons with intellectual and developmental disabilities (IDD) in Denton County.

This document requests participation from applicants for the purpose of providing intellectual and developmental disabilities (IDD) services as described in Attachment A to persons with intellectual and developmental disabilities (IDD), persons with pervasive developmental disorders, including autism, and persons with related conditions. The individuals to be served under this arrangement will meet the definition for the Priority Population for intellectual and developmental disabilities (IDD), which is included as Attachment A, and reside in Denton County.

There is no guarantee of a referral volume to any provider. It is expected that contracted programs/services will address issues of consumer choice, quality, access, price, and ultimate cost-benefit while assuring adherence to standards of care and service requirements.

Open enrollment documents are posted on The Center’s website at https://www.dentonmhmr.org/volunteers/contract-opportunities/. Notice is hereby given that The Center will receive applications for providers beginning February 2025. An original of the application and (1) copy of the attachments are due to:

ATTENTION:

Denton County MHMR Center Natalee Galvan contractsubmission@dentonmhmr.org

Center Background & General Information Denton County MHMR Center or “Local Authority” (Local Mental Health Authority “LMHA and Local Intellectual and Developmental Disability Authority “LIDDA”) is the Texas Health and Humas Services “HHS” designated authority established to plan, coordinate, develop policy, develop, and allocate resources, supervise, and ensure the provision of community based mental health and intellectual and developmental disability (IDD) Services for the residents of Denton County, Texas. The Center receives funding from many diverse sources that enable it to provide a variety of services for people who have needs related to behavioral health and/or intellectual/developmental disabilities. A board of Directors appointed by the Denton County Commissioners court governs The Center.

2519 Scripture Street Denton, Texas 76201 2509 Scripture Street, Suites 100, 101, 103, and 104, Denton Texas 76201 1614 Scripture Street Denton, Texas 76201 3835 Morse Street, Denton, Texas 76208 3827 Morse Suite 101, Denton, Texas 76208 and 1001 Cross Timbers Suites 1250 and 1040, Flower Mound, Texas 75028

(The Center is exempt from State and local sales tax and federal excise tax)

Pursuant to 25 Texas Administrative Code $ 412.5 and 40 Texas Administrative Code $2.55, the LMHA and LIDDA have the authority to acquire services to address needs of mental health and/or intellectual/developmental disabilities needs by certain procurement methods. This Request for Applications (RFA)/Open Enrollment invites and encourages the submission of applications (each, an “Application” and collectively, the “Applications,” and any party applying, and “Applicant”) from those interested in entering one or more contracts (each a “Contract” and collectively the “Contracts”) with The Center. Each qualified Applicant(s) under this RFA/Open Enrollment (each a “Successful Applicant” and collectively, the “Successful Applicants”) will be eligible to enter a Contract with The Center to provide one or more of the community-based services.

The individual who will be served under this arrangement each, a “Client” and collectively, “Clients” must always (a) meet the then current requirements of the funder of the services, and (b) reside in Denton County, Texas. An individual’s designation as a client may only be made by the Local Authority and must be documented in their record. This RFA/Open Enrollment invites the submission of Applications from those interest in being considered for a Contract with The Center for the purpose of offering services for Clients.

Mission Statement, Agency Principles, Vision, & Values Mission Statement Denton County MHMR Center enhances the quality of the individuals serves and their family members.

Diversity, Equity, and Inclusion At our Center, diversity and inclusion are an integral part of our mission and values. We strive to support an inclusive culture that celebrates, encourages, and supports our diverse staff and the community that we serve. When individuals feel respected and included, everyone can work collaboratively to create an innovative work atmosphere and a person-centered treatment environment for the individuals serves and their families.

Our Guiding Principles Denton County MHMR Center we believe these principles should guide our interactions with our clients and with interactions between our staff.

The Center’s Values are:

We respect each individual’s unique and special concerns by providing assistance to best fit their needs, that enhances their ability to live a full and dignified life, and that celebrates the contributions all individuals make to our community. Our core values are:

· Opportunity

The Center’s Vision Statement is:

We envision a DCMHMR Center

· That provides effective, comprehensive, and timely services to any and all people in need.

· Where a qualified, motivated, and caring staff strive to make a difference in the lives of those they serve.

· That offers state-of-the-art, high-quality facilities to assist individuals in living full and productive lives.

General Information The Center is wholly committed to equal opportunity for all potential respondents and does not discriminate, limit, segregate, or classify any individual or vendor with respect to respondent’s compensation, terms, conditions, or award of contract because of race, color, religion, gender, national origin, age, disability, political affiliation, sexuality, or other classifier defined by Local, State, and Federal Law.

The Center reserves the right to modify the general description and scope of services contained in the RFA/Open Enrollment by notifying potential applicants of any modifications.

If any of the provisions of the RFA/Open Enrollment conflict with applicable laws, rules, regulations, and/or other codes of professional ethics, the latter shall prevail over the provisions of the RFA/Open Enrollment.

The Center shall not reimburse potential contractors for any expenses incurred preparing applications in response to this request.

Any information that the respondent deems to be proprietary or otherwise confidential in the text of the application should be marked with red brackets or otherwise clearly designated as such. However, respondents are advised that the Center may disclose such proprietary information to appropriate parties if required to do so by applicable Texas open meetings and public record statues.

All questions and communications concerning the RFA/Open Enrollment, and process must be made in writing to the Procurement Analyst & Contract Developer only, at the following email address:

contractsubmission@dentonmhmr.org.

Note: Subject line of the email must read RFA/Open enrollment – Yes Waiver Note: It is the Centers intent to respond to all appropriate questions or convers received.

Purpose of the RFA/Open Enrollment

1. To provide a comprehensive community system of services and support.

2. To identify, implement, and evaluate successful programs based on client outcomes so that these efforts can be replicated.

3. To create meaningful cooperative relationships between the Local Authority and providers in the community.

4. To increase client access and allow client choice in the selection of qualified providers.

5. To provide quality services and achieve the desired outcomes at the most efficient cost possible.

Target Population The target population recipients are adults, adolescents, and children who have been identified with intellectual and developmental disabilities (IDD), autism and related conditions who have been identified by the Local Authority as Priority Population, in accordance with the definitions established by DADS. (See Intellectual and developmental disabilities (IDD) Priority Population.) Designation of an individual as a member of the Priority Population must be made by the Local Authority and documented in each individual's record maintained by the Local Authority. Levels of disability range from mild impairments to intellectual and physical disabilities.

Eligible Applicants Applicants must be registered with the Secretary of State in Texas and have a Tax Identification Number. Individuals providing professional services must hold valid Texas licenses and/or certifications as required by state law. In any situation where a consortium of providers is applying, a single entity responsible for services delivered must be identified and the financial agent must be an organization with a demonstrated ability to manage funds. Applicants may not subcontract responsibilities for these services. All service providers must be eighteen (18) years of age or older. Applicants may not have been convicted of a crime relevant to a person's duties including any sexual offense, drug-related offense, homicide, theft, assault, battery, or any other crime involving personal injury or threat to another person.

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Local Authority Responsibilities The Local Authority will be responsible for making referrals, authorizing services, reviewing claims, and paying for appropriate, authorized services rendered by the Applicant. The Local Authority is also responsible for utilization management and quality assurance. The length and type of service will be determined in collaboration with the individual, his/her family (when appropriate), the provider, and the Local Authority. All services contracted by Local Authority are reviewed for effectiveness and continued value to the individual (and when appropriate, the family) every ninety (90) days. The Local Authority ensures that contracted services addressing the needs of the Priority Population are provided as required by the Texas Department of Aging and Disability Services and comply with the rules and standards adopted under Section 534.052 of the Texas Health and Safety Code. The Local Authority does not guarantee any referral volume to any Network Provider.

Provider Responsibilities The Provider will be responsible for providing services as specified in the individual's plan of care. Provider must maintain all records regarding treatment and/or services rendered to individuals referred by the Local Authority for a period of five (5) years, and must allow the Local Authority immediate access during regular business hours to such records upon request. The Provider is required to comply with all state and federal laws regarding the confidentiality of consumers' records and nondiscrimination. The Provider must perform criminal history checks on employees to ensure that individuals convicted of crimes against people are not allowed to work with Local Authority consumers. The Provider will actively assist in the disbursement of consumer and advocate satisfaction surveys. The Provider will obtain prior authorization, provide acceptable levels of care, and maintain acceptable levels of liability insurance and appropriate licenses and accreditations. The Provider also agrees that its name may be used, along with a description of its facilities, care, and services in any information distributed by the Local Authority listing its providers. The Provider must comply with the rules and standards adopted under Section 534.052 of the Texas Health and Safety Code and applicable local, state, and federal laws, rules, and regulations.

Request for Application As a result of the passage of HB 2377, of the 74th legislature, the Texas Health and Human Services Commission has mandated that LIDDA’s assembling a network of service providers to serve people with intellectual and developmental disabilities. The DCMHMR Board of Directors has requested that the Executive Director develop a network of qualified providers willing to provide the following services sought for people with intellectual and developmental disabilities and/or related conditions in the least restrictive environment and the most integrated setting within the community.

INSTRUCTIONS FOR SUBMISSION FOR APPLICATIONS

To facilitate and ensure an objective review, Applicants must follow these instructions for submission. Denton County MHMR Center (The Center) expressly reserves the right to reject any application that is not submitted according to the instructions below.

Applicants must email (1) original of the completed application and one (1) copy of all applicable attachments to:

Email: contractsubmission@dentonmhmr.org Subject: ______________________

Applicants must follow the attached outline for submissions to facilitate objective review. The Center reserves the right to reject any and all applications, to waive technicalities, and to accept any advantages deemed beneficial to the Center and its clients. Please be sure to answer every question. If the question does not apply to your or your organization, simply and clearly document “N/A”.

False statements or false information provided by an Applicant may result in disqualification from or termination of enrollment into the network. In accepting applications, The Center reserves the right to reject any and all Applications, to waive formalities and reasonable irregularities in submitted documents, and to waive any requirements in order to take the action which it deems to be in the best interest of the Local Authority. The Center will not pay for any costs incurred by Applicants in the preparation and submission of a response to this RFA.

Each Applicant is responsible for ensuring that documents for potential enrollment are submitted completely and on time. The Local Authority expressly reserves the right not to evaluate any enrollment documents that are incomplete or late. Any attached form(s) must be completed by each Applicant to be considered for possible enrollment in the network.

Each Applicant shall be subject to disclosure under the Texas Public Information Act, Chapter 552 of the Texas Government Code, except for trade secrets and confidential information contained in the Application and clearly identified by the Applicant as such with blue ink. Such information may still be subject to disclosure under the Public Information Act and other applicable law.

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Attachment A

Intellectual and Developmental Disabilities (IDD) Priority Population

The Priority Population for intellectual and developmental disabilities (IDD) services includes those people who request and need services and possess one or more of the following conditions:

· Intellectual and developmental disabilities (IDD), as defined by Section 591.003 (13), Title 7, Health and Safety Code

· Autism as defined in the current edition of the Diagnostic and Statistical Manual (DSM)

· Pervasive Developmental Disorder (PDD) as defined in the current edition of the DSM.

· Eligibility for OBRA '87 mandated services for intellectual and developmental disabilities (IDD)/related condition The presence of intellectual and developmental disabilities (IDD) must be determined through the State Authority's (DADS) eligibility determination process or through the use of assessments performed by qualified professionals as per the Interagency Memoranda of Understanding. Diagnoses of autism or PDD must be reviewed and endorsed by the Local Intellectual and Developmental Disabilities (IDD) Authority admission team. For people with intellectual and developmental disabilities (IDD), autism, or PDD, the priority population includes only those individuals whose needs for services can be most appropriately met through programs currently or potentially offered by the DADS system rather than some other service system. Services are to be offered in coordination with the efforts of other agencies to ensure that all services are provided by agencies as required by laws, rules, and regulations. The priority population does not include anyone whose service needs may be most appropriately met through other means, as determined by DADS.

People who are members of the Priority Population are eligible to receive services from the DADS system. Since resources are insufficient to meet all the service needs of all the members of the Priority Population, services are provided to meet the most intense needs first.

Attachment B

Service Definitions and Rates

Day Habilitation $20.87 per day for each GR funded person Rate based on Level of Need for each authorized HCS and JCF-IDD funder person

Provider – Provider for day habilitation services must have a high school diploma or its equivalent and transportation is provided in accordance with applicable state laws.

Day Habilitation Services – The day habilitation service component assists an individual to acquire, retain, or improve self-help, socialization, and adaptive skills necessary to live successfully in the community and participate in home and community life and does not include services that are funded under the Rehabilitation Act of 1973 or the Individuals with Disabilities Education Act. The day habilitation component may not be provided at the same time supported employment, hourly-reimbursed Respite, or Community Support is provided. The day habilitation service component provides:

A. Individualized activities consistent with achieving the outcomes identified in the individual’s PDP;

B. Activities necessary to reinforce therapeutic outcomes targeted by other waiver service components, school, or other support providers;

C. Services in a group setting other than the individual’s home up to five days a week, six hours per day;

D. Personal assistance for individuals that cannot manage their personal care needs during the day habilitation activity;

E. Assistance with medications and the performance of tasks delegated by a registered nurse in accordance with state law; and F. Transportation necessary for the individual’s participation in day habilitation activities.

Specialized Therapies: Occupational Therapy*, Speech/Language Therapy* $72.95 per hour for each covered person for OT $74.12 per hour for each covered person for Speech

The specialized therapies service component provides assessment and treatment by licensed occupational therapists, speech, and language pathologists, and audiologists and includes training and consultation with an individual’s family members or other support providers.

Provider – Program provider must access that a provider of specialized therapies is licensed by the appropriate State of Texas licensing authority for the specific therapeutic service provided by the provider.

- APPLICATION -

Please indicate the service(s) you are applying for by checking in the box(es) below.

Refer to Attachment B for descriptions of services and rates.

Intellectual and Development Disabilities (IDD) Services

OPEN ENROLLMENT

꙱ Day Habilitation ꙱ Specialized Therapies* ꙱ Occupational Therapy ꙱ Speech / Language Therapy

*Servicers required completion of the “Texas Standardized Credentialing Application” for licenses providers: https://www.dentonmhmr.org/volunteers/contract-opportunities/

BUSINESS DEMOGRAPHICS

Organization/Individual Name: _____________________________________________ DBA: _______________________________Federal Tax ID #____________________________ Agency NPI Number: ______________________ Business Address: _____________________ Contact/Title: _____________________ Email Address: ______________________________ Address: __________________Phone: __________________Fax: _______________

Service Contact/Title: _____________________Email Address: _______________________ Address: __________________Phone: __________________Fax: _______________

Billing Contact/Title: _____________________Email Address: _______________________ Address: __________________Phone: __________________Fax: _______________

Business locations in this market area:

Street City County Zip Code 1.____________________________________________________________________________ 2.____________________________________________________________________________ 3.____________________________________________________________________________ 4.____________________________________________________________________________ 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 (please list below) □Yes □ No Is the business owner a current or former DCMHMR board member or employee? □Yes □ No

Is the business owner related to a current DCMHMR board member or employee? □Yes □ No If yes, who: __________________ Owners/Partners:

Name % Ownership If corporate, list organization 1._____________________________________________________________________________ 2._____________________________________________________________________________ 3._____________________________________________________________________________ 4._____________________________________________________________________________

Number of years in operation as a business: ________________________

Languages services provided in: _______________________________

Organization/individual certified as/or eligible to be a Historically Underutilized Business: Yes___ No _____ (If certified, provide Certification Number): __________________________

No employee of the Local Authority or DADS, and no member of the Local Authority's Board of Trustees can directly or indirectly receive any pecuniary interest from an award of the proposed contract. If such a situation exists, please explain in detail:

SERVICES

Identify the services that the organization/provider will provide: (Attach additional sheets for each service type if applying to provide more than one service. Examples of service types are speech therapy, physical therapy, occupational therapy, community support, etc.)

Will the organization/provider have qualified staff available to administer medications or to supervise individuals in the self-administration of medication? _______________________

What times of day and what days of the week are services available? (Complete for each service being applied for):

Service Type:___________________________

How many individuals can the organization/provider serve: _____________________

How long do people currently wait to get into the organization's/provider' s services: _________________________________________________________________________

Detail the specific population the organization/provider would serve. Include ages and level of severity and concurrent diagnosis:

Are there any restrictions on who the organization/provider will serve?

If yes, please explain: ________________________________________________________________________________

Describe the organization’s/provider’s experience in working with people with mental health or intellectual and developmental disabilities (IDD), autism, and related conditions over the last five (5) years:

Describe the organization’s/provider’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:

Describe the organization’s/provider’s experience in working with people with physical impairment and adaptive equipment:

Describe any specialized services you provide (ability to assist with eating, supervision, or self-medication, positioning, etc.):

Describe any "after hours" system for responding to client needs: _______________________

Can DCMHMR clients access services outside usual business hours: _______________________

Describe or attach (Label as III.N.) the organization’s/provider’s in-service training requirements for employees: ________________________________________________________________________________

EXPERIENCE

Provide copies of all licenses, credentials, certifications, and/or accreditations the organization or provider currently holds relative to this Application. Label as II.A.

Provide a summary of the most recent consumer satisfaction surveys or other on-going efforts to obtain and evaluate consumer satisfaction. Describe how this information was obtained and how it is used to improve quality:

Detail the specific population the organization/provider would serve. Include ages and level of severity and concurrent diagnoses:

Are there any restrictions on who the organization/provider will serve? If yes, please explain:

Describe abilities/experience working with diverse groups of individuals with regards to ethnic, racial, religious, and sexual orientation: (Attach additional pages as necessary)

Describe any limitations on capacity to serve the population (age ranges, total number of clients, geographical region, etc.): (Attach additional pages as necessary) ____________________________________________________________________________________________________________________________________________________________________________

Describe approach to working with individuals who are non-compliant with treatment: (Attach additional pages as necessary) ____________________________________________________________________________________________________________________________________________________________________________

QUALITY MANAGEMENT/UTILIZATION MANAGEMENT

Describe how organization/individual protects the security of individuals receiving services and their protected information. Attach any policies and procedures organization has implemented related to this area: (Attach additional pages as necessary)

Describe or attach a process to track, monitor, and investigation critical incidents (e.g., serious injuries, serious medication errors):

Describe how organization/individual prevents, identifies, and reports abuse, neglect, exploitation and rights violations pertaining to individuals receiving services, including the training of staff on these issues. Attach any policies and procedures organization has implemented related to this area: (Attach additional pages as necessary)

Describe how organization/individual identifies, controls, avoids, minimizes, and/or eliminates unacceptable risks to individuals receiving services and liability to the organization/individual.

Attach any policies and procedures the organization has implemented related to this area:

(Attach additional pages as necessary)

FINANCIAL

Is the organization/provider incorporated as "Profit," "Not-for-profit," or "Other?"

(If yes, attach a valid 501C IRS Exemption Form) If "Other," please explain: ________________________________________________________

Does the organization/provider have sufficient reserves or line of credit to operate during the time period between billing and receiving reimbursement from third party payors?

If not, please explain:

Provide name of Workers’ Compensation carrier if organization has Workers' Compensation coverage or self-funding documents if self-funded: _____________________________________ Has the organization/provider declared any type of bankruptcy in the prior seven (7) years?

Has the organization/provider received a "qualified" opinion on a financial statement in the past three (3) years? _______If yes, please explain:

Does the most recent audit report have any material instance of non-compliance with standard accounting practices? ______If yes, please explain:

Describe any arrangements to subcontract part or all of these services. Name all subcontractors and attach (Label as IV.E.) information on their staff credentials, licenses, and certifications:

Is the organization/provider currently under investigation, or have a license or accreditation revoked by any state/federal/DCMHMR or licensure agency, within the last five (5) years ______ If yes, please explain:

Has the organization/provider had any judgments or settlements against it within the last ten (10) years? ________ If yes, please explain: __________________________________________________________________________________________________________________________________________________________________________

Has the organization/provider been placed on "vendor hold" by any agency or government?

entity in the past three (3) years? If yes, please explain:

Does the organization/provider have a “Letter of Good Standing” which verifies that it is not delinquent in State Franchise Tax? ____________ Corporations that are non-profit or exempt from Franchise Tax are not required to have this letter but will have a 501C IRS Exemption form from the Comptroller’s Office. Attach the letter or exception form. Label as IV.I

Is the organization/provider delinquent in the payment of any court-ordered Child Support Payments? __________ If yes, explain: ________________________________________________________________________________________________________________________________________________________________________________

Is the organization/provider 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?

If yes, explain:

Describe anyone working for the organization/provider providing direct care or in management have any felony convictions? ________________ If yes, explain:

PROFESSIONAL LIABILITY INSURANCE

Organization and licensed/certified professionals must have professional liability insurance with limits of at least one (1) million each occurrence and three (3) million aggregate. Please attach policy certificate showing effective date and expiration date of coverage, per occurrence amount and aggregate amount.

Provide a Certificate of Insurance showing liability insurance coverage (property and vehicles, including riders) and include directors' and officers' professional liability, errors and omissions, and general liability insurance. Label as V.C.

RISK ASSESSMENT

Does anyone working for the organization/provider providing direct care or in management?

have any felony convictions? __________if yes, explain:

Describe the process, if any, the organization/provider uses to check on previous convictions of employees. Describe or attach (Label as V.A.) any policies and procedures regarding the hiring of a retention of people with criminal histories:

Has the organization/provider or its employees had any validated client abuse, client neglect, or rights violations claims in the last three (3) years? If yes, explain in detail: ____________________________________________________________________________________________________________________________________________________________________________

Describe or attach (Label as V.B.) any current policies and procedures regarding client abuse, client neglect, or rights violations and the training of staff in these issues:

Does the organization/provider currently have any malpractice claims pending or closed during the past five (5) years? ________ If yes, please supply the following information: Label as V.E.

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

2. Copies of the complaint and judgment

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

INFORMATION SYSTEMS

Organization/individual must have and maintain internet access and a current email account in order to be eligible to be a party to a contract.

a. Does organization/individual have internet access and a valid email address: Yes No

Can the organization/provider report data by the following categories:

1. Client name

2. Client's Local Authority identification number

3. Date, number, type, and duration of services rendered.

4. Authorization number

5. Amount to be paid.

6. If medications are administered or supervised, number, type, and severity of medication errors and adverse drug reactions for DCMHMR clients

7. Elopements or unauthorized departures from the program site

8. Confirmed abuse, neglect, or exploitation of DCMHMR clients.

9. Death or severe injury to DCMHMR clients occurring at program site.

RATE SCHEDULE

Applicants agree to accept the fees listed in Attachment B as payment in full for approved Covered Services. The Applicant will not submit a claim or bill or collect compensation from DCMHMR for any non-covered service. Applicant agrees that compensation for providing noncovered services will be solely between the client and the Applicant. The Covered Individual must be informed in writing, before any non-covered services are provided, that DCMHMR is not responsible for payment for such services. Clients are responsible for payment for non-covered services only if the Covered Individual consents in writing to the provision of such non-covered services. DCMHMR is the payor of last resort. If the services authorized for a Covered Individual are currently paid for by a third-party payor, applicant may not bill both entity for the same service.

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Attachment C Form-B

Credentialing and Attestation for Non-Licensed Providers (Must be completed on each non-licensed provider of services, including subcontractors)

Provider Name:

Last First MI Date of Birth: Social Security Number:

Driver’s license # Attach a copy of your driver’s license.

Have you ever been found to be perpetrator of a confirmed case of client abuse? ____Yes, ____No If so, please explain.

Have you ever been convicted of a felony? ____Yes, ____No If so, please explain.

Do you speak a language other than English? ____Yes, ____No If so, please explain.

Do you know sign language? ____Yes, ____No If so, please explain.

Education History – High School, Undergraduate, Graduate, and postgraduate education. Attach a copy of diploma or GED School Name City/State/Country

Degree

Year Received

Major

School Name City/State/Country

Degree

Year Received

Major

School Name City/State/Country

Degree

Year Received

Major

Continuing Education – Please list the continuing education programs relevant to the services you intend to provide that you have attended in the past two years. You may attach a current resume or other documentation of training.

Work History – For the past ten (10) years or since completion of highest degree. Attach a separate sheet if additional space is needed. You may submit a current resume to meet this requirement.

1.

Employer name Address City, State, Zip Code

Position title/description From - To

2.

Employer name Address City, State, Zip Code

Position title/description From - To

3.

Employer name Address City, State, Zip Code

Position title/description From - To

4.

Employer name Address City, State, Zip Code

Position title/description From - To

5.

Employer name Address City, State, Zip Code

Position title/description From - To

Have you ever been terminated with cause from any human service agency?

____Yes, ____No If so, please explain.

Attachment D

ATTESTATION

Are there any reasons you would be unable to perform the essential functions required with or without accommodation?

꙱ Yes, If yes, please explain on a separate sheet ꙱ No

I hereby attest to the following:

· I do not currently use any illegal drug.

· I have reported accurately and completely any reason(s) for any inability to perform the essential functions required with, or without, accommodation.

· I have accurately reported any history of felony convictions or client abuse and neglect.

· I have accurately reported any chronological work history.

· I consent to the inspection of records and documents pertinent to this Application, including the release by any person to Denton County My Health My Resources Center, dba Denton MHMR Center (the Center) of all information that may reasonably be relevant to an evaluation and verification of this Application or evaluation of professionals or institutions with which Organization/Individual has been or is currently associated.

· The information submitted in and with the application is complete and correct to the best of my knowledge.

Signature of Individual or Organization’s Authorized Representative

Date

Printed Name

Title (if applicable)

Organization/Program Name (if applicable) Attachment E

GENERAL AUTHORIZATION FOR RELEASE OF INFORMATION

I, the undersigned Individual, or authorized representative of Organization (acting on Organization’s behalf), hereby authorize Denton County My Health My Resource Center dba Denton County MHMR Center (The Center) to obtain any and all information required to complete a review and primary source verification of Organization/Individual’s credentials. Information and documents to be reviewed include, but are not limited to, licensure/certification, accreditations, education, and claims made against licensure/certification, malpractice insurance and claims.

I, the undersigned Individual or authorized representative of Organization, hereby release from liability and hold harmless for the consequences of any disclosure, to the fullest extent permitted by law, the named references in this Application and Denton County My Health My Resource dba Denton County MHMR Center (The Center) for their written and oral statements, decisions, and actions in connection with evaluating Organization/Individual’s Application for network approval including, without limitation, Organization/Individual’s experience, competencies and qualifications, health status, emotional stability, professional ethics, and character. Organization/Individual hereby releases from liability any and all individuals and organizations reviewing this Application for their acts performed in good faith and without malice in connection with evaluating this Application and the credentials and qualifications. Organization/Individual also released from any liability any and all individuals and organizations who provide information in good faith and without malice concerning the above release items.

A photostat, electronic or facsimile copy of this original statement constitutes Organization/Individual’s written authorization and requests to release any and all documentation relevant to Denton County My Health My Resource Center dba Denton County MHMR Center credentialing and/or network approval process. Such photostat, electronic or facsimile copy shall have the same force and effect as the signed original.

Signature of Individual or Organization’s Authorized Representative

Date

Printed Name

Title (if applicable)

Organization/Program Name (if applicable)

Attachment F

ASSURANCES DOCUMENT

For purposes of this Attachment F, the term “local government officer” with respect to Denton County MHMR Center means a member of Denton County MHMR Center Board of Trustees (see Attachment H), Denton County MHMR Center’s Chief Executive Officer (see Attachment H), and/or an agent of Denton County MHMR Center who exercises discretion in the planning, recommending, selecting, or contracting of the Contract (see Attachment H). The term “local public official” with respect to Denton County MHMR Center means a member of Denton County MHMR Center’s Board of Trustees (see Attachment H), or another agent of Denton County MHMR Center who exercises responsibilities beyond those that are advisory in nature (see Attachment H).

The term “family member” means a person related to another person within the first degree by consanguinity or affinity, as described by Subchapter B, Chapter 573 of the Texas Government Code. The term “family relationship” means a relationship between a person and another person within the third degree by consanguinity or the second degree by affinity, as those terms are defined by Subchapter B, Chapter 573, Texas Government Code.

Applicant Assures the Following:

21. Applicant is in good standing with all state and federal funding and regulatory agencies; is not currently debarred, suspended, or otherwise excluded from participation in federal, state, county or city contract or grant programs; is not delinquent on any repayment agreements; has not had a required license or certification revoked; has not had a contract terminated by HHSC; and has not voluntarily surrendered an obligation issued by HHSC or any other entity within the past three (3) years.

Signature of Authorized Representative Title (if applicable) Date

Attachment G

CERTIFICATION REGARDING LOBBYING, GRANTS, LOANS, & COOPERATIVE AGREEMENTS

The undersigned certifies, to the best of his or her knowledge and belief that:

1. No federal appropriated funds have been paid or will be paid, by or on behalf of the undersigned, to any person for influencing or attempting to influence an officer or an employee of any agency, a member of Congress in connection with the awarding of any federal contract, the making of any federal grant, the making of any federal loan, the entering into of any cooperative agreement, and the extension, continuation, renewal, amendment, or modification of any federal contract, grant,…