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RFI Process and Hub Onboarding Description
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 Supervisors attend required Hub trainings and meetings including: Hub Welcome, Intro to CCS Training, monthly Hub meetings.
PARTNER AGENCY APPLICATION
** Application does not save. Enter all responses then select 'Submit Application' **
*
1.
Name of Organization
(Required.)
*
2.
Address
(Required.)
Address
*
Address 2
City/Town
*
State/Province
*
AL Alabama
AK Alaska
AS American Samoa
AZ Arizona
AR Arkansas
CA California
CO Colorado
CT Connecticut
DE Delaware
DC District of Columbia
FM Federated States of Micronesia
FL Florida
GA Georgia
GU Guam
HI Hawaii
ID Idaho
IL Illinois
IN Indiana
IA Iowa
KS Kansas
KY Kentucky
LA Louisiana
ME Maine
MH Marshall Islands
MD Maryland
MA Massachusetts
MI Michigan
MN Minnesota
MS Mississippi
MO Missouri
MT Montana
NE Nebraska
NV Nevada
NH New Hampshire
NJ New Jersey
NM New Mexico
NY New York
NC North Carolina
ND North Dakota
MP Northern Mariana Islands
OH Ohio
OK Oklahoma
OR Oregon
PW Palau
PA Pennsylvania
PR Puerto Rico
RI Rhode Island
SC South Carolina
SD South Dakota
TN Tennessee
TX Texas
UT Utah
VT Vermont
VI Virgin Islands
VA Virginia
WA Washington
WV West Virginia
WI Wisconsin
WY Wyoming
ZIP/Postal Code
*
Email Address
*
Phone Number
*
*
3.
CEO / President
(Required.)
First Name
Last Name
Title
Phone Number
Email
*
4.
Financial Contact
(Required.)
First Name
Last Name
Title
Phone Number
Email
*
5.
IT Contact
(Required.)
First Name
Last Name
Title
Phone Number
Email
*
6.
CHW Supervisor Contact
(Required.)
First Name
Last Name
Title
Phone Number
Email
*
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. Additional training dates may be scheduled for CHWs and Supervisors when needed.
(Required.)
*
8.
Agency Information
(Required.)
Number of CHWs
Number Certified by Ohio Board of Nursing
Total FTE (CHWs)
Number of Licensed Professionals (RN, LPN, LISW)
Total FTE (Licensure)
Narrative
*
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).
(Required.)
*
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.
(Required.)
*
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).
(Required.)
*
12.
Indicate the primary reason your organization is interested in having your community health worker(s) work through the HCAN HUB (2000 character limit).
(Required.)
*
13.
List the organization's insurance coverage types (if available) and limits for: Professional liability, General liability, Cyber/technology, Workers Compensation.
(Required.)
*
14.
Document any potential issues/concerns with the expectations noted in the
expectations web page
for participating as a CCA with the HUB.
(Required.)
Attachments - PDF documents required
*
15.
Insurance Declaration Page
(Required.)
Include Insurance Declaration
Choose File
No file chosen
*
16.
Job Descriptions
(Required.)
Include the job description for your Community Health Worker(s) and supervisor(s).
Choose File
No file chosen
*
17.
Resumes
(Required.)
Include the resumes for the CHW supervisor(s) and the staff in the finance and IT positions.
Choose File
No file chosen
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.
*
18.
Signature
(Required.)
First Name
Last Name
Title
** Application does not save. Enter all responses then select 'Submit Application' **
