Hudson Partnership CMO Memorandum of Understanding

* 1. Provider/Agency Name:

* 2. Primary Address:

* 3. Secondary Address ( if applicable)

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

* 5. Contact Person for MOU:

* 6. Referral Information:

* 7. Provider/Agency is:

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

* 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.

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

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

* 12. Federal Tax ID Number:

* 13. Medicaid Number (if medicaid provider)

* 14. Cyber ID ( if applicable)

* 15. Check any services Provider/Agency offers

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

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

* 18. List fees of the services being provided.

* 19. Do you offer sliding scale or scholarships?

* 20. If yes, what are the qualifiers?

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

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

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