Hudson Partnership CMO Memorandum of Understanding

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* 1. Provider/Agency Name:

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* 2. Primary Address:

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* 3. Secondary Address ( if applicable)

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* 4. Billing Address ( if different from primary address)

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* 5. Contact Person for MOU:

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* 6. Referral Information:

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* 7. Provider/Agency is:

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* 8. Does your agency have an existing MOU with the Hudson Partnership CMO?

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* 9. If you answered yes to question number 8, 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.

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* 10. Please state any alternative or additional names used by your agency:

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* 11. List 3 references the Hudson Partnership CMO can contact (include telephone number and/or e mail:

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* 12. Federal Tax ID Number:

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* 13. Medicaid Number (if medicaid provider)

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* 14. Cyber ID ( if applicable)

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* 15. Check any services Provider/Agency offers

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* 16. If you provide evaluations, please list the types of evaluations you provide:

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* 17. If you provide specialized therapy, please list the type you provide:

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* 18. List fees of the services being provided.

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* 19. Do you offer sliding scale or scholarships?

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* 20. If yes, what are the qualifiers?

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* 21. Are Provider/Agency services reimbursable through insurance:

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* 22. If yes, please list insurance plans and the covered services.

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