Important Dates:
  • Deadline to apply is Friday, March 19, 2021, 5 p.m.
  • Send questions to info@healthcareaccessnow.org no later than March 18.
  • Expect to be notified regarding the status of your application on or before April 16.

1. Submit the Partner Agency Application. Applications will be reviewed by HCAN staff.􀃠
2. Interview: Selected applicants will be invited to an interview with key HCAN staff.􀃠
3. Legal agreements: Applicants selected to become a CCA will be notified and sent a HUB contract BAA.
4. HIPAA security/encryption verification:  Talbert House IT will ensure all devices (phones, tablets, desktops, laptops) are password protected, encrypted, and meet HIPAA security standards.
5. CHWs and Supervisor attend Pathways HUB training.
PARTNER AGENCY APPLICATION
** Application does not save. Enter all responses then select 'Submit  Application' **

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* 1. Name of Organization

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* 2. Address

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* 3. CEO / President

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* 4. Financial Contact

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* 5. IT Contact

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* 6. CHW Supervisor Contact

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* 7. CHW TRAINING & SUPERVISION

Confirm the willingness and availability of the supervisor and CHWs to participate in the HUB's Training sessions (2 half days); attend monthly Supervisor and CHW meetings; and monitor the CHW's work via the Care Coordination System (CCS) – the HUB's web-based electronic record and reporting system.

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* 8. Agency Information

Narrative

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* 9. Describe the organization's history and mission including the number of years serving the community. Include any significant recent and current organizational issues/changes, current programs and activities (2000 character limit).

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* 10. Describe the population you serve. Include the number of clients served by your agency in the last calendar year including the number of pregnant women, adults, and children.
Describe your geographic footprint for clients and provide a list of the zip codes served by your organization.

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* 11. Outline the organization's experience with regard to strategies or activities related to reducing low birthweight, premature birth, infant mortality, and chronic disease among the Medicaid eligible population (2000 character limit).

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* 12. Indicate the primary reason your organization is interested in having your community health worker(s) work through the HCAN HUB (2000 character limit).

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* 13. List the organization's insurance coverage types (if available) and limits for: Professional liability, General liability, Cyber/technology, Workers Compensation.

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* 14. Document any potential issues/concerns with the expectations noted in the expectations web page for participating as a CCA with the HUB.

Attachments - PDF documents required

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* 15. Job Descriptions

PDF file types only.
Choose File

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* 16. Resumes

PDF file types only.
Choose File
By submitting this application, your organization and its personnel assures they can meet the HUB expectations for participating as a CCA as noted in the "Expectations" section of this
web page.

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* 17. Signature

** Application does not save. Enter all responses then select 'Submit Application' **

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