Exit RFP Process and HUB Onboarding Process 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' ** Question Title * 1. Name of Organization Question Title * 2. Address Address * Address 2 City/Town * State/Province * -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code * Email Address * Phone Number * Question Title * 3. CEO / President First Name Last Name Title Phone Number Email Question Title * 4. Financial Contact First Name Last Name Title Phone Number Email Question Title * 5. IT Contact First Name Last Name Title Phone Number Email Question Title * 6. CHW Supervisor Contact First Name Last Name Title Phone Number Email Question Title * 7. CHW TRAINING & SUPERVISIONConfirm 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. Question Title * 8. Agency Information Number of CHWs Number Certified by Ohio Board of Nursing Total FTE (CHWs) Number of Licensed Professionals (RN, LPN, LISW) Total FTE (Licensure) Narrative Question Title * 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). Question Title * 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. Question Title * 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). Question Title * 12. Indicate the primary reason your organization is interested in having your community health worker(s) work through the HCAN HUB (2000 character limit). Question Title * 13. List the organization's insurance coverage types (if available) and limits for: Professional liability, General liability, Cyber/technology, Workers Compensation. Question Title * 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 Question Title * 15. Job Descriptions Include the job description for your Community Health Worker(s) and supervisor(s). PDF file types only. Choose File Choose File No file chosen Remove File Include the job description for your Community Health Worker(s) and supervisor(s). Question Title * 16. Resumes Include the resumes for the CHW supervisor(s) and the staff in the finance and IT positions. PDF file types only. Choose File Choose File No file chosen Remove File Include the resumes for the CHW supervisor(s) and the staff in the finance and IT positions. 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 thisweb page. Question Title * 17. Signature First Name Last Name Title ** Application does not save. Enter all responses then select 'Submit Application' ** Submit Application
