MOU Application Hudson Partnership CMO Memorandum of Understanding Question Title * 1. Provider/Agency Name: (Required.) Question Title * 2. Primary Address: (Required.) Street Address City State Zip Code Question Title * 3. Secondary Address (If Applicable) Street Address City State Zip code Question Title * 4. Billing Address (If Different From Primary Address) Street Address City State Zip code Question Title * 5. Contact Person for MOU: (Required.) Contact Person Contact Telephone Contact Email: Question Title * 6. Referral Information: State Whether You Are Non-Profit, For Profit, or Sole Proprietor Alternative Names Used By Agency/Provider Federal Tax ID Number NPI Number Medicaid Number (If Medicaid Provider) Cyber ID (If Applicable) Primary Phone Number Additional Phone Number Fax General Agency Email Referral Email (If different from general agency email) Services Are Offered In What Language/s? Do You Have Staff Working In The Hudson County Area? If So, How Many? Are Services In-Person, Virtual, or Hybrid? Question Title * 7. Does your agency have an existing MOU with the Hudson Partnership CMO?' (Required.) Yes No Question Title * 8. If you answered yes to question number 7, please submit the MOU changes or updates below. You do not need to complete the rest of the application. If you answered no, please provide a brief description of your agency and the services offered below. Question Title * 9. Is your agency currently working with any Hudson Partnership CMO youth? (Required.) No If Yes, Who Is The Care Manager For The Youth? Question Title * 10. List 3 references the Hudson Partnership CMO can contact (Include phone number & email address) (Required.) Question Title * 11. Check Non-Clinical Flex Fund Services Mentoring Recreation Translation Other (please specify) Question Title * 12. Check services to be provided through CYBER Medicaid authorization: IIC BA ISS IIH ABA IIH Clinical Parent Mentoring/Coaching (via IIC) BPS BPS-Substance Use Other (Please Specify) Question Title * 13. Private Pay Outpatient Clinical Services Individual psychotherapy Group psychotherapy Comprehensive Psychological Evaluation Neurodevelopmental Evaluation Psychological Evaluation with Fire Setting Risk Assessment Psychosexual Evaluation/Risk Assessment Psychiatric Evaluation Other (please specify) Question Title * 14. If you provide specialized therapy, please list the type you provide: Question Title * 15. List session duration and fees of services provided that are not reimbursed by Medicaid. Question Title * 16. Do you offer sliding scale or scholarships? Yes No Question Title * 17. If yes, what are the qualifiers? Question Title * 18. Are Provider/Agency services reimbursable through insurance outside of Medicaid? (Required.) Yes No Question Title * 19. If yes, please list insurance plans and the covered services. Question Title * 20. Provide A Staff Directory And Indicate Licensed Providers, Unlicensed Providers, & Providers Pending License Question Title * 21. All Staff Professional/Clinical Licenses (as one file) Question Title * 22. Liability insurance (Required.) Question Title * 23. Workers' Compensation Insurance Question Title * 24. Can You Confirm Licensed Providers Have Active NJ Licenses? Yes No If No, Indicate Who: Question Title * 25. If A Provider's License Is Up For Renewal, Have They Already Applied For Renewal? Yes No If No, Indicate Who: Question Title * 26. Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Question Title * 27. CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Question Title * 28. CONTINUED: Provide Additional Material (Brochures, Pamphlets, Posters, Etc.) Relating To Your Agency & Its Services That May Be Useful To Your Application & That We Can Provide To Hudson Partnership CMO Staff & Upload To Our Hudson Service Network Site. Page1 / 1 100% of survey complete. Done