For IPRS (State Funds) and Medicaid Services

Managing Mental Health, Intellectual/Developmental Disabilities and Substance Abuse Services

910-673-9111 (FAX) 910-673-6202 www.sandhillscenter.org Victoria Whitt, CEO

P.O. Box 9, West End, NC 27376 24-Hour Access to Care Line: 800-256-2452

TTY: 1-866-518-6778 or 711 Serving Anson, Guilford, Harnett, Hoke, Lee, Montgomery,

Moore, Randolph & Richmond Counties

Provider Agency/Facility Application

For IPRS (State Funds) and Medicaid Services

Please submit application to:

Sandhills Center for MH, I/DD & SAS Network Operations Dept.

Credentialing Specialist P.O. Box 9

West End, NC 27376

SHC Agency/Facility Credentialing Application (IPRS & Medicaid) qmcappd 11/28/17 Page 2

Instructions for SHC Provider Credentialing Application A provider agency/facility must apply for and be credentialed with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center Members. Additionally, agencies must have a signed contract with Sandhills Center to qualify for reimbursement of services provided to Sandhills Center members. A. This application must be completed in its entirety, with all questions addressed and required information

submitted. An application is considered to be invalid and will be returned to the provider for correction and/or for additional information if:

1. The version date on any of the documents that comprise the provider application packet is prior to October 2017. Older versions are not accepted.

2. Any spaces in the application are not completed. (Please indicate “N/A” or “None” if the question is not applicable).

3. The “Attestation Statement” Signature is not original and dated 4. The text has been altered, highlighted, struck through, or obstructed through the use of correction fluids. 5. The contact person’s name and title is not completed 6. The signatures, where required, are not original 7. The signatures are not by the individual applicant or, where applicable, an authorized agent for the group or

entity 8. The responses are illegible. The National Provider Identifier is not a valid number 9. Any of the documents or pages that comprise the “Provider Agency/Facility Credentialing Application” is

missing. 10. Any of the requested information in any of the documents that comprise the “Provider Agency/Facility

Credentialing Application” is missing, with the exception of the fax number and e-mail address. B. Sandhills Center shall notify the provider within ten (10) business days of receipt of the completed application or if

materials are missing. The application and materials will be returned if incomplete. NOTE: There must be an approved executed contract between the Agency/Facility and Sandhills Center prior to service delivery. If the Agency/Facility has Licensed Independent Practitioners (LIP’s) or Provisional Licensed Practitioners (PLP’s) it is the responsibility of the Agency/Facility to ensure that each Practitioner completes and submits the “Uniform Application to Participate as a Health Care Practitioner”. Upon approval of the Practitioner’s Credentialing status by the Sandhills Clinical Advisory Committee the Agency/Facility can submit claims for services provided by the LIP or PLP back to the Board Approval Date.

Before submitting the Credentialing Application, make sure you have completed the following: Include an answer in all spaces. Indicate “N/A” or “None”, if the question is not applicable. The Authorized agent for the group or entity has signed and dated all pages requiring signature within the

Credentialing Application Any requested information in any of the documents that comprise the Credentialing Application is not missing,

with the exception of the fax number. Any of the required accreditation documentation is not missing Copy of the Certificate of Insurance for your current commercial general, professional liability, and workers’

compensation (if there is more than three employees) indicating by name, provider(s) covered, coverage amounts, effective date, expiration date, policy numbers and Sandhills Center should be listed as certificate holder. (Sandhills Center cannot accept Notice of Intent as proof of insurance), stating liability amounts equal or greater than $1,000,000 / $3,000,0000 aggregate

Submit proof of automobile insurance for company vehicles, and employee vehicles that are used to transport members include contracted employees – please complete included waiver regarding auto insurance form.

Copy of National Provider Identifier (NPI) Certification Letter for Agency Completed W-9 Form signed and dated Current Valid Enrollment with NCTracks to include all of the service site addresses


Instructions for SHC Provider Credentialing Application (continued)

Submit written documentation of source of authority through charter, constitution and/or by-laws or articles of incorporation.

If an out-of-state Organization, submit a certificate of authority that shows eligibility to do business in NC (obtained from the Secretary of State’s office).

If an Organization is privately owned, submit listing of duties of Owner/CEO/COO. Provide documentation of qualifications via resume/curriculum vitae.

Original completed Attestation Letter signed and dated (included in this application). Submit an Organization Chart. This chart will include any major programs, program heads/supervisors as well as

staffing patterns for the Agency. The chart will also show the Organizations standing committees and their reporting structure as well as any ancillary positions.

Submit an annualized budget and the most recent certified audit or most recent board approved financial statement.

Submit CFO statement of financial capacity (for profit only). Submit list of board of directors (names, titles and contact). Provide documentation of the Board by-laws on that

includes required qualifications of board members, method to determine a quorum, and officer’s length of term. (Sole Proprietors are excluded from this item requirement).

Submit a listing of Client Rights Committee members, which includes names, title, and contact information. Copy of facility license (if applicable) Sandhills Center will schedule an on-site visit for unlicensed sites. Each provider facility/site must be accommodating for members with physical disabilities. If facility is not

accommodating, please provide an explanation of how those members with physical disabilities would be accommodated.

Original signed and dated Trading Partner Agreement (included in this application). Copy of Conflict of Interest Policy and Procedure For each of the following written references include the reference person’s name, address, telephone, and e-mail

information. All references must be submitted as originals. No copies will be accepted. Each reference must specifically address: • One from an individual outside the Organization familiar with fiscal operations of the facility. If the

Organization is a new business, the reference must pertain to the fiscal stability of the board/CEO/COO/Owner to support the company fiscally.

• One from an individual familiar with the clinical operations of the Organization. If the Organization is a new business the reference must be obtained from someone familiar with the clinical director’s qualifications and abilities.

• Two from individuals currently receiving services and /or family members. If the Organization is a new business, the references must be obtained from individuals involved in the field of disabilities either professionally or through life experience.

Please submit the following sample forms and documents that demonstrate compliance with the following regulations.

• Sample Service Notes/Documentation • Sample Treatment Plan/Person Centered Plan • Sample Staff Supervision Plan and Note • Sample Staff Schedule • Sample Job Description

Sandhills Center is interested in a clear understanding of each agency’s organizational qualifications as it related to services or disability group. Please provide a detailed description of the following items:

A. Agency description including: Mission and Philosophy and Vision B. Describe the Agency’s expertise with services provided and priority populations. This should include how

the Agency has developed their overall expertise in the areas of service delivery, access to training and ongoing use of consultation, which will assure adherence to the service definition.

C. Describe how the Agency has developed and maintained the expertise of the Agency in service delivery area requested and priority population’s. This answer should be very specific and describe how supervision is done, including the credentials of staff and management. If the service is a nationally recognized best practice, please include what the Agency does to assure fidelity to model.


Instructions for SHC Provider Credentialing Application (continued)

For individuals with 5% or greater ownership in the Organization, original signed and dated SBI Authority for Release of Information form (included in this application).

For individuals with 5% or greater ownership in the Organization, original signed and dated Acknowledgement and Authorization for Social Security Number Check form; must be completed with all personal information (included in this application).

Please describe any local, state, or national recognition that the Agency has received for the service area and all national accreditations.

If national Accreditation is required for the service, please submit your Agency’s Strategic Plan to achieve this within the timelines established.

If peer certification is required for the service, please describe how the Agency will achieve this. Define what steps if any your Agency has taken to achieve cultural competency. Description of how your Agency will operationalize or has operationalized the new service Please submit results of any client satisfaction surveys and if you are a new Agency, a detailed plan and timeline of

how this will be obtained including the types of questions and frequency to be administered. List all services that you are requesting to provide. The services must be listed according to the North Carolina

Department of Health & Human Services Division of Mental Health, Developmental Disabilities, and Substance Abuse MH/DD/SA Services Definitions (ex. not group home but (ex.) supervised living moderate). Information to be documented, per service includes:

• State Classification of the Service • Consumer capacity • Ages to be served • Disability population to be served • Screening and assessment process • Admission criteria • Discharge criteria • Please include the proposed job descriptions of the staff for the service(s). • Minimum qualifications of staff for the service • Staffing pattern • Sample of the staffing schedule for PSR, Residential, Day Treatment, Day and Night Services that

demonstrates staffing at the ration required by the State Service Definitions • Description of the initial competency training program for staff that is to be offered as required by the

specific service definition. This should include specifics on the training curriculum, who will provide the training, and how competencies will be determined. Cultural Competency Training is required.

• On call support system (clinical) • On call support system (medically) • Are the services within thirty (30) miles of Consumers in Sandhills Center catchment area

Include information related to the Agency’s use of person centered and/or recovery models of service. Please include specific examples of how this is demonstrated on a day-to-day basis.


Important Points to Remember: a) If services are being provided at multiple sites, you are required to list each site in this application and they will

be assigned a separate site ID number for each location. Each site must also specify the services that will be rendered at that location.

b) Copies of the applicable accreditation documentation must accompany the application. If these documents are missing, the application will be returned to the provider.

c) Retain a copy of your completed Credentialing Application and all documentation submitted with the Credentialing application for your records. Providers will be notified via email from Sandhills Center upon receipt of their application.

d) Providers are assigned a provider number and are notified by mail once the enrollment and contract process has been completed. Please do not submit claims for dates of services prior to the effective date.

e) Billing information and clinical coverage policies are available on Sandhills Center website at: http://www.sandhillscenter.org

f) Providers are requested to include on their application the name, e-mail address, and fax number of the individual contact person at their site who is responsible for receiving Sandhills Center Health Plan information.

We want to thank you in advance for your efforts in completing your Credentialing application process in the manner stated above. Submitting an organized application will expedite the review process and increase

efficiency and accuracy. Please ensure that all applicable information requested is submitted to avoid delays with processing.


Section 1: Agency Information Date of Application: ___________________ 1. Legal Name of Organization (as used for tax reporting purposes):

2. Federal Tax ID #: 3. NPI #:

Please specify the Federal Tax Status: Not for Profit For Profit 501 C 3 4. Taxonomy #(s): List all applicable to the agency. 5. Is the Agency enrolled in NCTracks? Yes No (If “No”, provide Enrollment Registration # and Submission Date) Registration #: Submission Date: 6. Organization Legal Entity Type: C-Corporation Sole Proprietorship General Partnership Limited Liability Corporation Limited Liability Partnership 7. Organization Address: ______________________________ _____________ _________ ________________ Street City State Zip+4 (Required)

(Must be the physical address – no P.O. Box) 8. Check (√) County of Address : Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: 9. Website Address: 10. Number of years doing business under this name: 11. Has this Organization ever been in business under a different name? Yes No

If yes, what name? 12. Primary Contact: 13. Title: 14. Email Address: 15. Phone #: 16. Executive Director: 17. Clinical/Medical Director: 18. Email Address: 19. Phone #: 20. Have background checks been completed on the owners, directors, officers, administrators and staff? Yes No (If yes, please attach a policy and procedure and supporting documentation. If no, please provide explanation.) 21. Is this Organization accredited? (If yes, attach verification of accreditation) : Yes No JCAHO: Yes No Most recent date accredited: Expiration date: CARF: Yes No Most recent date accredited: Expiration date: COA: Yes No Most recent date accredited: Expiration date: CQL: Yes No Most recent date accredited: Expiration date: OTHER: Yes No Most recent date accredited: Expiration date: If no, please identify, if applicable, the Accrediting body your agency/facility has selected and your current status in the

accreditation process as required by the NC Division of MH/IDD/SAS. Note: Refer to SECTION 10.15A. (c) Article 3A of Chapter 122C of the General Statutes. Sandhills Center “General

Credentialing & Re-Credentialing Criteria” stipulates the specific services that require accreditation.


Section 1: Agency Information continued

22. Has the Organization ever been sanctioned, placed on probation or lost accreditation or certification status Yes No

(If yes, please attach an explanation and any supporting documentation.) 23. Liability Insurance: a) Have you had a claim against you?

(If yes, please list the name & amounts of the Insurance & disposition.) Yes No

b) Are there any current unsettled claims? (If yes, please attach explanation.) Yes No

c) Are you aware of any circumstances that may result in a claim or suit? (If yes, please attach explanation.) Yes No

d) Have you ever had a policy cancelled? (If yes, please attach explanation.) Yes No

24. Has there been any action or investigation against you or any owner or qualified professional in your Organization relating to: (If yes, please attach explanation.)

License Yes No

Registration Yes No

Billing Organization Yes No

Certification Yes No

Privileges Yes No

Sanctions Yes No

25. Have any adverse actions been filed against you by: (If yes, please attach explanation.)

Medicaid Yes No Medicare Yes No Other Insurance Yes No 26. Has the organization ever been sanctioned, placed on probation or lost accreditation or certification status?

(If yes, please attach explanation of the circumstances and how it was resolved.) Yes No 27. Has your organization or anyone within your organization who has an ownership, managerial or clinical role

been sanctioned by any professional organization or government organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence, negligence, lost accreditation or certification status in any state or country? Yes No (If yes, please attach explanation of the circumstances and how it was resolved.)

28. Are you aware of any circumstances that may result in such an action? (If yes, please attach explanation.) Yes No

29. Have you ever had a contract cancelled by another LME-MCO, Area Authority, County Program in North Carolina or similar entity in another state? Yes No (If yes, please attach explanation.)

30. Has anyone in your company who has an ownership, managerial or clinical role ever been convicted of a felony or misdemeanor, or is under investigation with respect to such conduct? Yes No (If yes, please attach explanation.)

31. If you are enrolling as a group provider, list all shareholder/partners (including self) who have 5% or more ownership (or whose spouse, parent, child or sibling as such an interest) and all individual officers, directors, managers, and electronic funds transfer (EFT) authorized individuals and information requested on each. (This page may be duplicated if necessary.)

Name:

Date of Birth:

Address: Street City State Zip+4 (Required) Title: SSN: License #: % Owner:



Check business relationship that applies: Owner Shareholder Partner Officer/Director Manager EFT Authorized Employee Check relationship to enrolling provider (if applicable): Spouse Parent Child Sibling

Name: Date of Birth: Address: Street City State Zip+4 (Required) Title: SSN: License #: % Owner: Check business relationship that applies: Owner Shareholder Partner Officer/Director Manager EFT Authorized Employee Check relationship to enrolling provider (if applicable): Spouse Parent Child Sibling



32. Identify other providers, if any, which are owned or operated by the applicant under the same owner name. Provider Name: Address: Street City State Zip+4 (Required)



Relationship type: Nursing Home Home Health Agency Community Based Residential Facility Hospital 33. Is the applicant a subsidiary company, either wholly or partially owned by another organization or business: Yes No (If yes, please provide the following information.): Legal Business Name (parent company): Type of Ownership:

34. Please attach and list all relevant contracts your Organization currently has and/or has had for the past five

(5) years. (Skip to the next question if you have no contracts). Please include for each:

A. Contracting Organization/Area Program LME/MCO • Contact name • Phone number • E-mail address

B. What services are/were provided C. Beginning and ending dates D. Dollar amount of contract


Section 2: Site Specific Credentialing

FACILITY/SITE SPECIFIC INFORMATION – A facility/site is a physical location where supervision and/or management of services occur. Please attach the facility site license if applicable.

If your Organization operates more than one facility/site, copy and complete SECTION 2 for each facility/site. 1. Facility/Site Name: 2. Facility/Site Address: Street City State Zip+4 (Required) 3. Check (√) County of Address: Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: 4. Facility/Site Days/Hours of Operation:

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

5. Phone #: 6. Fax #: 7. Email: 8. Please List all National Provider Identifier (NPI) and Taxonomy Numbers that pertain to this site:

NPI Numbers Taxonomy Numbers 9. Please list services to be provided at this site Service Code(s) Service Description


Section 2: Site Specific Credentialing (continued)

10. Information about the Facility/Site Director/Supervisor Facility/Site Director’s Name & Credentials: Facility/Site Director’s Education: (If necessary add additional page(s) Facility/Site Director’s Credentials: Facility/Site Director’s Phone #: Facility/Site Director’s Email: 11. Is this facility/site staffed and equipped to serve: (If no, please explain how you plan to accommodate below.) Physically Disabled: Yes No Deaf & Hearing Impaired: Yes No Blind/Visually Impaired: Yes No Behaviorally Disruptive: Yes No Sexually Aggressive: Yes No Foreign Languages: Yes No Foreign Languages please specify:

Plan to accommodate those members with physical disabilities: 12. Is this facility/site licensed by (if yes, attach a copy of the license): DHSR: Yes No License #: State: DSS: Yes No License #: State: Other: Yes No Type: 13. Coverage: Indicate what arrangements you have made to cover member emergency situations during nights, weekends, and holidays: 14. Physician Coverage: Indicate what arrangements you have made to cover your Organization for members who

need psychiatric evaluation or psychiatric medication. List psychiatrist/physician who will see your members: Name: Phone: Name: Phone: Name: Phone: 15. Do you have a manmade, natural disaster, or act of God crisis/disaster plan? Yes No (if yes, please attach) 16. SHC will schedule Health and Safety Review to review personnel, training, medication, facility and medical

records, if applicable.



SANDHILLS CENTER Site Specific

Cultural, Gender, and Linguistic Data Form

By providing the information below, you will be assisting Sandhills Center with member/provider matching as well as providing information necessary for analyzing the Network and its ability to meet our Members cultural, racial, ethnic and linguistic needs. This information will reside within Sandhills Center Provider

Directory and the online Provider Search. Name of Agency Site:

Population(s) that you serve (please check (√) all that apply):

Early Childhood (0-4) Child & Adolescent (5-21) Adult (22+) Geriatrics (55+) Female Gay & Lesbian HIV/Aids Hearing Impaired* Male Gender Identity Issues Sexually Reactive/Aggressive Youth Visually Impaired**

* Deaf and Hard of hearing – hearing impaired equipment/services are offered by provider.

** Visually Impaired – facility is set up with Braille signage and brochures/forms/documents.

Culturally diverse populations the Agency feels competent to treat (please check (√) all that apply): White Black or African American American Indian and Alaska Native Asian, Pacific Islander Hispanic or Latino Other:

Language(s) the Agency are able to communicate in fluently (please check (√) all that apply): The agency must explain or attach their organizational plan for sustaining their ability for the interpretation

services checked below – direct language services through hiring staff or other translation entities.

NOTE: Do not consider licensed individual practitioners as part of your agency languages. Sandhills Center has already collected the clinicians’ languages spoken that will be credited toward your Agency. American Sign Language English French German Hmong Portuguese Russian Spanish Telugu Other: Yes No - Completed Cultural Competency Training.



SANDHILLS CENTER Site Specific

Practice Preference Data

Focus of Treatments the Agency Provides (please check (√) all that apply):

Mental Health Intellectual/Developmental Disabilities Chemical Dependency/Substance Abuse Eating Disorder Co-Occurring/Dual DX-Mental Illness, Mental Health, Substance Abuse Agency Expertise/Certified Specialties (please check (√) all that apply):

Psychiatry Self-Direction Psychological Testing Crisis Services Marriage & Family Counseling Therapeutic Foster Care Outpatient Therapy MST (Multisystemic Therapy) Intensive In-Home Therapy Residential Services Inpatient Services Trauma Focused Services Community Based Services Detoxification Services Faith Based Services Co-Location with/Primary Care Physician Telemedicine Day/Hours of Operation:

Sunday

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Counties Where Agency is Physically Present and Services are Provided:

Anson Guilford Harnett Hoke Lee Montgomery Moore Randolph Richmond Other: Website Address (if applicable):

Provider Contact Phone #:

Printed Name Signature Date:

Thank you for taking the time to submit this form. If this form is not completed and returned, your agency will not

appear within the Sandhills Center online Provider Search.


Section 3: SIGNATURE AUTHORIZATION PAGE

Authorization to File Credentialing Application

To the best of my knowledge, my Agency is able to meet all requirements necessary to apply for Sandhills Center Credentialing. I am submitting the attached Sandhills Center Provider Credentialing Application, which, to my knowledge, is a true and complete representation of the requested materials. Printed Name

Authorized Signature Date Title


Please List Independent Practitioners:

If the Agency/Facility has Licensed Independent Practitioners (LIP’s) or Provisional Licensed Practitioners (PLP’s) it is the responsibility of the Agency/Facility to ensure that each Practitioner completes and submits the “Uniform Application to Participate as a Health Care Practitioner” (if new with the Agency/Facility) or the “Uniform Credentialing Application to Participate as a Health Care Practitioner”.

Please list all Licensed Independent Practitioners (LIP) their Taxonomy #, NPI #, and License Type who are

currently seeing Sandhills Center members. (You may make copies of this page if more space is needed/ please print)

LIP Name License Type NPI Taxonomy

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30


Outpatient Behavioral Health Service Codes for IPRS & Medicaid Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Procedure Code Description

Available to Benefit Plan State

(IPRS) Medicaid

90785 Interactive Complexity Add On State Medicaid 90791 Psychiatric Diagnostic Evaluation State Medicaid 90792 Psychiatric Diagnostic Evaluation with Medical Services State Medicaid 90832 Psychotherapy 30 Minutes State Medicaid 90833 Psychotherapy 30 Minutes Add On State Medicaid 90834 Psychotherapy 45 Minutes State Medicaid 90836 Psychotherapy 45 Minutes Add On State Medicaid 90837 Psychotherapy 60 Minutes State Medicaid 90838 Psychotherapy 60 Minutes Add On State Medicaid 90839 Crisis Psychotherapy first 60 Minutes State Medicaid 90840 Crisis Add For Each Additional 30 Minutes State Medicaid 90845 Psychoanalysis N/A Medicaid 90846 Family therapy w/o Patient State Medicaid 90847 Family therapy with Patient State Medicaid 90849 Group Therapy (Multiple Family) State Medicaid 90853 Group Therapy (Non-Multi Family) State Medicaid 90857 Interactive Group Therapy N/A Medicaid 96101 Psychological Testing F-T-F State Medicaid 96110 Developmental Testing Limited State Medicaid 96111 Developmental Testing Extended State Medicaid 96116 Neurobehavioral Status Exam State Medicaid 96118 Neuropsychological Testing State Medicaid 96372 Therapeutic, Prophylactic, or DX Injection Intra-Muscular State Medicaid


Evaluation & Management Codes

***Evaluation & Management Codes are only provided by Physician Assistants, Certified Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***

Check (√)

Procedure Code Description Check

(√) Procedure

Code Description

90865 Narcosynthesis for Psychiatric Diagnostic and Therapeutic Purposes

99220 Hospital Initial Observation Care High Complexity

95970 Electronic Analysis of Implanted Neurostimulator

99221 Hospital Initial Care MD (30 min.)

95971 Electronic Analysis of Implanted Neurostimulator Simple Spinal Cord


95972 Electronic Analysis of Implanted Neurostimulator Complex Spinal Cord (1hr.)


95973 Electronic Analysis of Implanted Neurostimulator Complex Spinal Cord (30 min.)

99231 Hospital Subsequent Hospital Care MD

Low Complexity (15 min.)

95974 Electronic Analysis of Implanted Neurostimulator Complex Cranial (1 hr.)

99232 Hospital Subsequent Hospital Care MD Moderate Complexity (25 min.)

95975 Electronic Analysis of Implanted Neurostimulator Complex Cranial (30 min.)

99233 Hospital Subsequent Hospital Care MD High Complexity (35 min.)

95978 Electronic Analysis of Implanted Neurostimulator

99234 Hospital Observation/Inpatient Care Low Complexity

95979 Electronic Analysis of Implanted Neurostimulator (30 min.)

99235 Hospital Observation/Inpatient Care Moderate Complexity

96125 Standardized Cognitive Performance Testing 99236 Observation/Inpatient Care High Complexity

96150 Physical Health and Behavior Assessment F-T-F (15 min.)

99238 Hospital Discharge Services (<30 min.)

95151 Physical Health and Behavior Reassessment 99239 Hospital Discharge Services (>30 min.)

96372 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Muscular

99241 Outpatient Consultation MD Minor (15 min.)

96373 Therapeutic, Prophylactic, or Diagnostic Injection Intra-Arterial

99242 Outpatient Consultation MD Moderate (30 min.)

96374 Therapeutic, Prophylactic, or Diagnostic Injection Intravenous Push

99243 Outpatient Consultation MD Severe (40 min.)

96375 Therapeutic, Prophylactic, or Diagnostic Injection Subsequent Intravenous Push

99244 Outpatient Consultation MD Severe (60 min.)

99201 Outpatient E&M New Patient F-T-F (10 min.) 99245 Outpatient Consultation MD Severe (80 min.) 99202 Outpatient E&M New Patient F-T-F (20 min.) 99251 Inpatient Consultation MD Minor (20 min.)

99203 Outpatient E&M New Patient F-T-F (30 min.) 99252 Inpatient Consultation MD Low Severity (40 min.)

99204 Outpatient E&M New Patient F-T-F (45 min.) 99253 Inpatient Consultation MD Moderate (55 min.)

99205 Outpatient E&M New Patient F-T-F (60 min.) 99254 Inpatient Consultation MD Moderate – High Severity (80 min.)

99211 E & M Estab Patient, w/wo MD (approx. 5 min.)

99255 Inpatient Consultation MD Moderate – High Severity (110 min.)

99212 Outpatient Visit Estab. Minor (10 min.) 99281 ER Visit, Minor 99213 Outpatient Visit Estab. Moderate (15 min.) 99282 ER Visit, Low Severity 99214 Outpatient Visit Estab. Severe (25 min.) 99283 ER Visit, Moderate Severity 99215 Outpatient Visit Estab. Severe (40 min.) 99284 ER Visit, High Severity

99217 Hospital Observation Care - Discharge 99285 ER Visit for the evaluation and management of a patient

99218 Hospital Initial Observation Care Low Complexity

99304 Initial Nursing Facility Care E&M Low Complexity (25 min.)

99219 Hospital initial Observation Care Moderate Complexity

99305 Initial Nursing Facility Care E&M Moderate Complexity (35 min.)

99306 Initial Nursing Facility Care E&M high Complexity (45 min.)

99337 Estab. Patient Domiciliary/Rest Home E&M Moderate to High Severity (60 min.)


Evaluation & Management Codes (continued) ***Evaluation & Management Codes are only provided by Physician Assistants, Certified Nurse Practitioners and Physicians (only check (√) what services you are currently providing). ***

99307 Subsequent Nursing facility Care E&M Review of Case (10 min.)

99341 New Patient Home Visit E&M Low Severity (20 min.)

99308 Subsequent Nursing Facility Care E&M Low Complexity (15 min.)

99342 New Patient Home Visit E&M Low Complexity (30 min.)

99309 Subsequent Nursing Facility Care E&M Moderate Complexity (25 min.)

99343 New Patient Home Visit E&M Low Moderate Complexity (45 min.)

99310 Subsequent Nursing Facility Care E&M High Complexity (35 min.)

99344 New Patient Home Visit E&M High Severity (60 min.)

99315 Nursing Facility Discharge Management; (<30 min.)

99345 New Patient Home Visit E&M High Complexity (75 min.)

99316 Nursing Facility Discharge Management; (>30 min.)

99347 Estab. Patient Home Visit E&M (15 min.)

99318 Nursing Facility, E&M Low to Moderate Complexity (30 min.)

99348 Estab. Patient Home Visit E&M Low Complexity (25 min.)

99324 New Patient Domiciliary/Rest Home E&M Low Severity (20 min.)

99349 Estab. Patient Home Visit E&M Moderate Complexity (40 min.)

99325 New Patient Domiciliary/Rest Home E&M Low Complexity (30 min.)

99350 Estab. Patient Home Visit E M High Complexity (60 min.)

99326 New Patient Domiciliary/Rest Home E M Moderate Complexity (45 min.)

99354 Prolonged MD Service w/F-T-F Patient Contact in Office (60 min.)

99327 New Patient Domiciliary/Rest Home E&M High Severity (60 min.)

99355 Prolonged MD Service w/F-T-F Patient Contact in Office (30 min.)

99328 New patient Domiciliary/Rest Home E&M High Complexity (75 min.)

99356 Prolonged MD Service w/F-T-F Patient Contact Inpatient (60 min.)

99334 Estab. Patient Domiciliary/Rest Home E&M (15 min.)

99357 Prolonged MD Service w/F-T-F Patient Contact Inpatient (30 min.)

99335 Estab. Patient Domiciliary/Rest Home E&M Low Complexity (25 min.)

Q3014GT TelePsyc Site Facility Fee

99336 Estab. Patient Domiciliary/Rest Home E&M Moderate Complexity (40 min.)

IPRS (State) Funds Only - Service Codes for NON-Licensed Substance Abuse Professionals

Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check (√)


YP830 Behavioral health Assessment YP831 Behavioral health Counseling and Therapy YP832 DMH Outpatient Treatment Group YP833 DMH Outpatient Tx Family Therapy w/ Client YP834 DMH Outpatient Tx Family Therapy w/o Client YP835 Alcohol and/or Drug Services; Group Counseling by Clinician


IPRS (State) Funds Only

Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check (√)

Procedure Code Description Check

(√) Procedure

Code Description

H2014 Developmental Therapy – Prof- Ind. YP010 Hourly Respite - Individual H2014HM Developmental Therapy – Para Prof – Ind. YP011 Hourly Respite – Group H2014HQ Developmental Therapy – Prof- Group YP020 Personal Assistance – Individual H2014U1 Developmental Therapy – Para Prof – Group YP021 Personal Assistance – Group H2034 SA Halfway House YP230 Assertive Outreach YA125 Hourly Respite YP450 Deaf Interpretation YA213 Community Respite YP485 Facility Based Crisis YA230 Psychiatric Residential Treatment Facility YP610 Developmental Day

YA308 Peer Support Individual YP620 Adult Developmental Vocational Program (ADVP)

YA309 Peer Support Group YP630 Supported Employment – Individual – MH

YA343 Peer Support Hospital Discharge and Diversion

YP640 Supported Employment – Group - MH

YA345 Jail Diversion YP650 Community Rehab Prg (Shelter Work) YA352 Assertive Engagement Qualified Prof YP660 Day Activity YA353 Assertive Engagement Assoc./Para Prof YP710 Supervised Living – Low

YA389 Supported Employment Long Term Vocational – IDD

YP720 Supervised Living – Mod

YA390 Supported Employment – Individual - IDD YP730 Community Respite YM050 Personal Care YP740 Family Living – Low YM645 Long Term Support - MH YP750 Family Living – Mod YM700 Independent Living – MR/MI YP760 Group Living – Low YM755 Family Living – High YP770 Group Living – Moderate YM811 Supervised Living – 1 Residential YP780 Group Living – High YM812 Supervised Living – 2 Residential YP790 Detox – Social Setting YM813 Supervised Living – 3 Residential YP820 Inpatient Hospital YM814 Supervised Living – 4 Residential YP821 3-Way Hospital Contract

YM815 Supervised Living – 5 Residential YP851 Public Psychiatry – Administrative Functions

YM816 Supervised living – 6 Residential YP852 Public Psychiatry – Consultative Services


Enhanced Mental Health & Substance Abuse Service Codes for IPRS & Medicaid Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check

(√) Procedure

Code Description

0183 Therapeutic Leave H0010 Non-Hosp Medical Detox H0012HB Comm Residential Tx-Adult H0013 Medical Comm Residential Tx H0014 Ambulatory Detox H0015 Alcohol and Drug Services Intensive Outpatient H0019UQ Residential Level III 1-4 beds (Former Y2348) H0019US Residential Level III 5+ beds (Former Y2349) H0019US Residential Level IV (Former Y2360) H0020 Methadone Administration H0035 Partial Hospital H0040 Assertive Community Treatment Program (ACTT) H0046 High Risk Intervention Level I H2011 Mobil Crisis Management H2012HA Day Treatment – Child H2015HT Community Support Team H2017 Psychosocial Rehabilitation H2020 Residential Level 2 Group Home-High Risk H2022 Intensive In-Home H2033 Multi-Systemic Therapy H2035 SA Comprehensive Outpatient Treatment H2036 Medically Supervised Detox/Crisis Facility S5145 Child Foster Care, Therapeutic, Level II S9484 Crisis Intervention (Facility Based Crisis) S9484A Facility Based Crisis Program-Children and Adolescents T1023 Diagnostic Assessment


B-3 Medicaid Services Only Please check (√) all that apply. (Only the services you have an existing agreement with Sandhills Center.)

Check (√)


H2023U4 Supported Employment – IDD H2023U4HE Supported Employment-MH H2023HQU4 Supported Employment Group H2026U4 Long Term Supported Employment - IDD H2026U4HE Long Term supported employment—MH H0038U4 Peer Support H0038HQU4 Peer Support Group H0045HAU4 Individual Respite – Child H0045HBU4 Individual Respite - Adult H0045HAHQU4 Respite Group - Child H0045HBHQU4 Respite Group – Adult T2041U4 Community Guide

Innovations Medicaid Services Codes Only

Please check (√) all that applies (Only the services you have an existing agreement with Sandhills Center.) Check

(√) Procedure

Code Description Check

(√) Procedure

Code Description

H2011HI Primary Crisis Response T2013TFER Community Living and Supports-Enhanced Rate

H2015 Community Networking T2013TFHQ Community Living and Supports-Group

H2015HQ Community Networking Group T2014 Residential Supports Level 2 H2015U1 Community Networking Class/Conf. T2020 Residential Supports Level 3 H2016 Residential Supports Level 1 T2021 Day Supports – Ind. H2016HI Residential Supports Level 4 T2021HQ Day Supports – Grp. H2025 Supported Employment-Individual T2025 Specialized Consultative Service H2025HQ Supported Employment – Group T2025U1 Financial Supports

H2025TS Supported Employment-Long Term Follow Up

T2025U2 FM Supplies

H2025TSHQ Supported Employment – Long Term Follow Up Group

T2025U3 Crisis Behavioral Consultation

S5110 Natural Supports Education T2027 Day Supports – Developmental Day S5111 Natural Supports Educ. – Conf. T2029 Assistive Technology: Equip. Supplies S5150 Respite Care – Community Individual T2033 Supported Living-Level 1 S5150HQ Respite Care –Community Group T2033HI Supported Living-Level 2 S5150US Respite Care –Community Facility T2033TF Supported Living-Level 3 S5165 Home Modifications T2034 Out of Home Crisis T1005TD Respite Care Nursing-RN T2038 Community Transition Supports T1005TE Respite Care Nursing-LPN T2039 Vehicle Adaptions T1999 Individual Goods & Services T2041 Community Guide/Navigator

T2013TF Community Living and Supports T2041U1 Community Guide/Navigator Training – Employer


ICF – MR Medicaid Service Only

Please check (√) all that apply.

Check

(√) Procedure

Code Description

0183 Therapeutic Leave ICF - MR 0100 ICF-MR

PRTF Medicaid Only Service Code

Please check (√) all that apply.

Check

(√) Procedure

Code Description

0183 Therapeutic Leave PRTF 0911 PRTF

If you are currently providing a service that is NOT listed above, please type the service code and description below.



Population Information

Member/Age/Disability/Gender Check (√) all populations served:

Please indicate with a check (√) only the services you have an existing agreement with Sandhills Center, another LME/MCO or Client Specific Agreement to deliver or are currently providing to Sandhills Center area eligible members: (Place a (√) for all counties to be served)

1. Periodic

(√ )

Serv

ices

Mem

ber

Cap

acity

(to

tal #

for a

ll co

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s ser

ved)

Acc

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Patie

nts (

Y/N

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Har

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a Assertive Community Treatment Team (ACTT)

b Community Support - Team

c Diagnostic Assessment

d Emergency Services/Assessments (ED Physicians only)

e Inpatient Psychiatric Physician Services

f Intensive In-Home

g Mobile Crisis Management

h Multi Systemic Therapy (MST)

i Outpatient Opioid Treatment

j Peer Support

k Substance Abuse Comprehensive Outpatient Treatment (SACOT)

l Substance Abuse Intensive Outpatient (SAIOP)

m Other (please specify)

Age and Disabilities Served (Check (√) all that apply) Child/Adolescent Adult Mental Health (MH)

Substance Abuse (SA)

Intellectual/Developmental Disabilities (I/DD)

Gender(s) Served Male

Female


Please indicate with a check (√) only the services you have an existing agreement with Sandhills Center to deliver or are currently providing to Sandhills Center area eligible members: (Place a (√) for all counties to be served)

2. Day / Night

(√ )

Serv

ices

Mem

ber

Cap

acity

(to

tal #

for a

ll co

untie

s ser

ved)

Acc

eptin

g N

ew

Patie

nts (

Y/N

) A

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Gui

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H

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M

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a Child & Adolescent Day Treatment

b Partial Hospitalization (PH)

c Psychosocial Rehabilitation (PSR)

d Other (please specify)

3. Residential – 24 Hour

(√ )

Serv

ices

Mem

ber

Cap

acity

(to

tal #

for a

ll co

untie

s ser

ved)

Acc

eptin

g N

ew

Patie

nts (

Y/N

)

Ans

on

Gui

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M

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y

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d

a Ambulatory Detoxification

b Facility Based Crisis Program

c Residential Level II – Program Type

d Residential Level III

e Residential Level IV

f Professional Treatment Services in Facility Based Crisis Program

g Psychiatric Residential Treatment Facilities (PRTF)

h Substance Abuse Medically Monitored Community Residential Treatment

i Substance Abuse Non-Medical Community Residential Treatment

j Other (please specify)


Please indicate with a check (√) only the services you have an existing agreement with Sandhills Center to deliver or are currently providing to Sandhills Center area eligible members: (Place a (√) for all counties to be served)

4. Residential Level II – Family Type

(√ )

Serv

ices

Mem

ber

Cap

acity

(to

tal #

for a

ll co

untie

s ser

ved)

Acc

eptin

g N

ew

Patie

nts (

Y/N

) A

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Gui

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a Residential Level II – Family Type

5. Outpatient Therapy

(√ )

Serv

ices

Mem

ber

Cap

acity

(to

tal #

for a

ll co

untie

s ser

ved)

Acc

eptin

g N

ew

Patie

nts (

Y/N

) A

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Gui

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a Outpatient Therapy






Attestation Statement

No Stamps or Copies Please (Original Only) This Application is to be signed by the individual who has authorization to submit an application on behalf of this

agency/facility.

All information submitted by me in this application, as well as any attachments or supplemental information, is true, current, and complete to my best knowledge and belief as of the date of signature below. I fully understand that any significant misstatement in this application may constitute cause for denial of my application or termination of a resulting participation agreement. By application for membership in Sandhills Center Network, I signify my willingness to appear for an interview in regards to my application. I authorize Sandhills Center to consult with administrators and members of the medical staffs of hospitals or institutions with which I have been associated and with other, including past and present malpractice carriers, who may have information bearing on the questions in this application. Upon request, I will obtain and provide to Sandhills Center materials pertaining to my qualifications and competence, including, materials relating to complaints filed, any disciplinary actions, suspensions, or actions to curtail my medical - surgical privileges. I further consent to the inspection by representatives of Sandhills Center of all documents that may be material to an evaluation of my professional qualifications and competence. I understand and agree that I, as an applicant, have the burden of producing adequate information for proper evaluation of my professional competence, character, ethics, and other qualifications and for resolving any doubt about such qualifications. I release from liability all representatives of Sandhills Center for their acts performed in good faith and without malice in connection with evaluating my application and my credentials and qualifications, and I release from any liability, all individuals and organizations that provide information to Sandhills Center in good faith and without malice concerning this application and I hereby consent to the release and verification of information relating to any disciplinary actions, suspensions, or curtailment of medical - surgical privileges to Sandhills Center. I understand that if my application is rejected for reasons relating to my professional conduct or competence, Sandhills Center may report the rejection to the appropriate state licensing board and/or National Practitioner Data Bank. In the event I am accepted for participation in Sandhills Center Network, I hereby consent to Sandhills Center for inspection of my patient records relating to Sandhills Center members as necessary for its peer and utilization review purposes as permitted by state or federal laws and regulations. I further agree to notify Sandhills Center in a timely manner (not to exceed 30 days) of any changes to the information requested on the application.

Print Name of Agency / Facility above

Print Name of Authorized Agent to sign the application on behalf of the Agency / Facility above

Signature of Authorized Agent above Date






Trading Partner Agreement

TRADING PARTNER AGREEMENT– Electronic Data Interchange (EDI) This document constitutes an agreement to the following provisions for exchanging Electronic Data Interchange (EDI) between the Trading Partner and Sandhills Center (SHC). The Trading Partner agrees: 1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the Health

Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there under and to take no action which adversely affects SHC’s HIPAA compliance.

2. That it will promptly notify SHC of any and all unlawful or unauthorized disclosures of confidential information or

protected health information (PHI) that comes to its attention and will cooperate with SHC in the event any litigation arises concerning the unauthorized use, transfer, or disclosure of either confidential or protected health information.

3. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and

protect all participant-specific data from improper access. 4. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)

Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

5. That it will establish and maintain procedures and controls so that information concerning SHC health plan

participants or any information obtained from SHC, shall not be used by agents, officers, or employees of the trading partner other than for its sole intended purpose.

6. That the information stated in any EDI Trading Partner Profile(s) submitted with this Agreement, or subsequently is

correct and complete. 7. That it will allow SHC 30 days after receipt of written notice from the Trading Partner if there is any change in the

trading partner representative or location where electronic transactions are sent. 8. That it is bound by this written agreement to comply with state and federal law, if the trading partner is an

intermediary for the billing provider. SHC agrees:

1. To conform to the requirements for Administrative Simplifications as defined in the provisions of the Health

Insurance Portability and Accountability Act (HIPAA) of 1996 (P.L. 104-91), and regulations promulgated there under and to take no action which adversely affects the trading partner’s HIPAA compliance.

2. That it will use sufficient security procedures to ensure that all transmissions of documents are authorized and protect all participant-specific data from improper access.

3. That it will ensure that all files transmitted comply with the appropriate national Electronic Data Interchange (EDI)

Transaction Set Implementation Guide, in effect on the date of transmission, as provided by the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

Both parties agree:

1. That documents will not be considered as received and no responsibility assigned until accessible at the receiving party’s computer.

2. That upon receiving any documents, to prepare and transmit a timely response or an acknowledgement of transaction

receipt. If acceptance of a document is required, a document is not considered received until an acceptance acknowledgement is returned.

3. To notify the other party within a reasonable time frame if any transmitted data are received in an unintelligible or

garbled form. 4. That each party will provide and maintain the equipment, software, services, and testing necessary to transmit and

receive documents. 5. To conduct business and perform as required by this agreement and any applicable rules or regulations. 6. That this agreement will remain in effect until terminated by either party with at least 30 days prior written notice.

The notice will specify the effective date of termination, but will not affect the obligations or rights of either party prior to the effective date of termination. This agreement is automatically terminated in the event the trading partner is disqualified through a federal administrative action or state action. That any document transmitted according to this agreement will be considered an original and signed when received.

Effect of Termination

1. Except as provided in paragraph (2) of this section or in the contract or by other applicable law or agreements, upon

termination of this agreement and services provided by the Trading Partner, for any reason, the Trading Partner shall return or destroy all Protected Health Information received from SHC, or created or received by Trading Partner on behalf of SHC. This provision shall apply to Protected Health Information that is in the possession of subcontractors or agents of the Trading Partner. Trading Partner shall retain no copies of the Protected Health Information.

2. In the event that Trading Partner determines that returning or destroying the electronic protected health information

is not feasible, Trading Partner shall provide to SHC notification of the conditions that make return or destruction not feasible. Trading Partner shall extend the protections of this agreement to such Protected Health Information and limit further uses and disclosures of such Protected Health Information to those purposes that make the return or destruction infeasible, for so long as Trading Partner maintains such Protected Health Information.

Trading Partner Name Street Address Line 1 (Site/Physical Address, not a P.O. Box)

Street Address Line 2

City, State, Zip Code

Contact Information (Phone Number, email address) ____________________________________________________________________________________ Signature of Applicant or Authorized Individual Date Printed Name and Title

___________________________________________________________________________________ For Sandhills Center for MH, DD & SAS use only

Trading Partner’s EDI Submitter ID: Sandhills Center for MH, DD & SAS Receiver ID: SHC303 Please return completed form to: Sandhills Center for MH, DD & SAS P.O. Box 9 West End, NC 27376 Attn: EDI Coordinator, Information Technology Department

AUTHORITY FOR RELEASE OF INFORMATION State Access Only

Name Check Access I authorize the North Carolina Department of Justice through the State Bureau of Investigation to perform a North Carolina name-based criminal history record information check in connection with my application for employment, my employment or volunteer services with SANDHILLS CENTER FOR MENTAL HEALTH pursuant to DHHS-LONG TERM – STATE AND FED – NCGS 122C-80B/131 D-40A A1/131D-40A A1.

(type or print clearly)

Last Name

First

Middle

Maiden

Social Security #

Date of Birth

Sex

Race

I understand that the North Carolina State Bureau of Investigation, officials and employees shall not be held legally accountable in any way for providing this information to the above named agency, and I hereby release said agency and persons from any and all liability which may be incurred as a result of furnishing such information. I further understand that the above named agency cannot provide a HARD COPY of the results of this criminal history record check to me. *Disclosure of social security number is entirely voluntary and not required. If disclosed, the social security number will be utilized to assist with accurate identification/exclusion of possible criminal history records. Applicant’s/Employee’s/Volunteer’s Signature ____________________________________ Date _____________________________________ This form must be maintained on file with the above named agency for one year. UPON COMPLETION OF THIS FORM, MAIL A PHOTOCOPY TO THE ADDRESS INDICATED BELOW:

State Bureau of Investigation Criminal Information and Identification Section Attn: Applicant Unit Post Office Box 29500 Raleigh, North Carolina 27626-0500 ORI # HCP000008 – SANDHILLS CENTER FOR MENTAL HEALTH

HCP000008






WAIVER REGARDING

AUTO AND WORKERS’ COMP INSURANCE COVERAGE

Dear Provider: Sandhills Center is now requiring that all agency applicants provide proof of auto and worker’s comp insurance coverage or sign a waiver stating that the auto and worker’s comp insurance is not required. If your agency does not have the aforementioned insurance coverage, we ask that you please complete, sign and date the waiver below as part of your agency’s Sandhills Center application. I, ______________________________, attest to the following regarding Auto and Workers’ Comp Liability coverage for Please Print Name _______________________________________________________________________________: Please Print Agency Name Agency does have Auto Liability coverage, and I have attached proof of auto insurance coverage. Agency does not have Auto Liability coverage, and I have attached an explanation on agency letterhead as to why

not. I hereby acknowledge that by checking this option and providing the aforementioned explanation, Sandhills Center is reasonably relying upon these representations in making a decision on my credentialing application.

Agency does have Worker’s Comp Liability coverage, and I have attached proof of Workers’ Comp insurance

coverage. Agency does not have Worker’s Comp Liability coverage, and I have attached an explanation on agency letterhead as

to why not. I hereby acknowledge that by checking this option and providing the aforementioned explanation, Sandhills Center is reasonably relying upon these representations in making a decision on my credentialing application.

________________________________________________ Provider Signature ____________________ Date

Indemnification Agreement: By signing this waiver, I hereby agree to indemnify and hold harmless Sandhills Center from all losses, costs, damages, claims, liabilities and expenses (including attorneys’ fees and court costs) whatsoever, which may arise or be claimed against Sandhills Center, for any loss, injuries or damages, consequent upon or arising from any acts, omissions, neglect or fault in connection with Sandhills Center’s reliance upon this waiver.

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qmcappd 05/22/2018

ACKNOWLEDGEMENT AND AUTHORIZATION FOR SOCIAL SECURITY NUMBER CHECK

I, , hereby authorize Sandhills Center to verify my

(Print Name)

Social Security Number through a third party consumer reporting agency for credentialing/re- credentialing purposes. This verification will be conducted by American DataBank, 110 Sixteenth St., 8th

Fl., Denver, CO 80202, 1-800-200-0853, www.americandatabank.com. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

All of the information requested below is mandatory and must be provided. Please type or print clearly.

Last Name: First Name: Middle:

Social Security Number*: Date of Birth*:

Present Address:

City/State/Zip:

Email Address: Signature: Date:

*This information is limited to verification of the individual’s Social Security Number and will not be used for employment/hiring purposes. American DataBank’s privacy policy can be found at http://www.americandatabank.com/consumer-information/privacy-policy/.

qmcappd 10/12/2017

Documents

For IPRS (State Funds) and Medicaid Services