The following formation is being collected to update contract services information and the ACBH Resource Directory.

Today’s Date:	Contract Year:
Provider Name:
Main Address:
Main Phone #:	Fax #:
Email:	Agency Website:

Executive Director:	Financial Officer:
Name:	Name:
Phone:	Phone:
Email:	Email:

Billing Contact/Title:	OIG Attestation Contact/Title:
Name:	Name:
Phone:	Phone:
Email:	Email:

Please provide information for each Program as you would like it to appear in the Resource Directory.

Program Name:	Program Name:
Director:	Director:
Address:	Address:
Phone:	Phone:
Email:	Email:

Program Name:	Program Name:
Director:	Director:
Address:	Address:
Phone:	Phone:
Email:	Email:

Program Name:	Program Name:
Director:	Director:
Address:	Address:
Phone:	Phone:
Email:	Email:

Program Name:	Program Name:
Director:	Director:
Address:	Address:
Phone:	Phone:
Email:	Email:

Please provide information about your Board of Directors.

ACBH is requesting additional information from our contracted providers about Board Membership per our recent audits. The information you provide below will help ACBH to meet current audit requirements and help ACBH to evaluate whether a more comprehensive policy is needed at some point in the future.

Board President Name:	Board Member Name:
Title:	Title:
Address:	Address:
Phone:	Phone:
Email:	Email:
Voting Board Member: Yes No	Voting Board Member: Yes No
Paid Staff: Yes No	Paid Staff: Yes No
Related to another Board Member/Owner:* Yes No	Related to another Board Member/Owner:* Yes No
Other Interested Party:** Yes No	Other Interested Party:** Yes No

Board Member Name:	Board Member Name:
Title:	Title:
Address:	Address:
Phone:	Phone:
Email:	Email:
Voting Board Member: Yes No	Voting Board Member: Yes No
Paid Staff: Yes No	Paid Staff: Yes No
Related to another Board Member/Owner:* Yes No	Related to another Board Member/Owner:* Yes No
Other Interested Party:** Yes No	Other Interested Party:** Yes No

Board Member Name:	Board Member Name:
Title:	Title:
Address:	Address:
Phone:	Phone:
Email:	Email:
Voting Board Member: Yes No	Voting Board Member: Yes No
Paid Staff: Yes No	Paid Staff: Yes No
Related to another Board Member/Owner:* Yes No	Related to another Board Member/Owner:* Yes No
Other Interested Party:** Yes No	Other Interested Party:** Yes No

* Please check yes if spouse, parent, child or sibling of another Board Member/Owner within this organization.

** Please see definition of Interested Party on Internal Revenue Service (IRS) website.

If you require more space for programs or board members, please add them on additional sheets.

For-Profit Organizations Only: Please provide information about Ownership.

ACBH is requesting additional information from our contracted providers about individuals with a 5% or more ownership interest in your organization (as defined under 42 CFR sec. 455.104) per our recent audits. The information you provide below will help ACBH to meet current audit requirements.

Name of Owner:	Name of Owner:
Title:	Title:
Address:	Address:
Phone:	Phone:
Email:	Email:
Paid Staff: Yes No	Paid Staff: Yes No
Related to Board Member/Other Owner:* Yes No	Related to Board Member/Other Owner:* Yes No
Percent of Ownership:	Percent of Ownership:
Other Interested Party:** Yes No	Other Interested Party:** Yes No

Name of Owner:	Name of Owner:
Title:	Title:
Address:	Address:
Phone:	Phone:
Email:	Email:
Paid Staff: Yes No	Paid Staff: Yes No
Related to Board Member/Other Owner:* Yes No	Related to Board Member/Other Owner:* Yes No
Percent of Ownership:	Percent of Ownership:
Other Interested Party:** Yes No	Other Interested Party:** Yes No

Name of Owner:	Name of Owner:
Title:	Title:
Address:	Address:
Phone:	Phone:
Email:	Email:
Paid Staff: Yes No	Paid Staff: Yes No
Related to Board Member/Other Owner:* Yes No	Related to Board Member/Other Owner:* Yes No
Percent of Ownership:	Percent of Ownership:
Other Interested Party:** Yes No	Other Interested Party:** Yes No

* Please check yes if spouse, parent, child or sibling of another Board Member/Owner within this organization.

** Please see definition of Interested Party on Internal Revenue Service (IRS) website.

If you require more space for programs or board members, please add them on additional sheets.