Hudson Partnership CMO Memorandum of Understanding

Provider/Agency Name:

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* 1. Provider/Agency Name:

Primary Address:

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* 2. Primary Address:

Secondary Address ( if applicable)

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* 3. Secondary Address ( if applicable)

Billing Address ( if different from primary address)

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

Contact Person for MOU:

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* 5. Contact Person for MOU:

Referral Information:

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* 6. Referral Information:

Provider/Agency is:

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* 7. Provider/Agency is:

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

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

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.

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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.

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

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

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

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

Federal Tax ID Number:

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* 12. Federal Tax ID Number:

Medicaid Number (if medicaid provider)

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* 13. Medicaid Number (if medicaid provider)

Cyber ID ( if applicable)

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* 14. Cyber ID ( if applicable)

Check any services Provider/Agency offers

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* 15. Check any services Provider/Agency offers

If you provide evaluations, please list the types of evaluations you provide:

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

If you provide specialized therapy, please list the type you provide:

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

List fees of the services being provided.

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* 18. List fees of the services being provided.

Do you offer sliding scale or scholarships?

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* 19. Do you offer sliding scale or scholarships?

If yes, what are the qualifiers?

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* 20. If yes, what are the qualifiers?

Are Provider/Agency services reimbursable through insurance:

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

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

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

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