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

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* 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.

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* 9. Is your agency currently working with any Hudson Partnership CMO youth?

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* 10. List 3 references the Hudson Partnership CMO can contact (Include phone number & email address)

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* 11. Check Any Services Agency/Provider Offers:

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

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

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* 14. List session duration and fees of services provided that are not reimbursed by Medicaid.

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* 15. Do you offer sliding scale or scholarships?

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* 16. If yes, what are the qualifiers?

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* 17. Are Provider/Agency services reimbursable through insurance outside of Medicaid?

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

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* 19. Provide A Staff Directory And Indicate Licensed Providers, Unlicensed Providers, & Providers Pending License

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* 20. All Staff Professional/Clinical Licenses (as one file)

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* 21. Liability insurance

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* 22. Workers' Compensation Insurance

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* 23. Can You Confirm Licensed Providers Have Active NJ Licenses?

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* 24. If A Provider's License Is Up For Renewal, Have They Already Applied For Renewal?

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* 25. 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.

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* 26. 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.

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* 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.

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100% of survey complete.

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