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Contract Renewal / Mental Health / MHP FFS Provider Forms / Substance Use Disorder / Standard



Contract Renewal Documents Standard Documents for FY 23-24 Exhibit A Attachments Exhibit A: Table of Contents (Template) Exhibit A-1: Standard Requirements for Mental Health (MH) Contracts – Coming Soon Exhibit A-1: Standard Requirements for Substance Use Disorder (SUD) Contracts – Coming Soon Exhibit A-2: CBO Lobbying Restrictions & Disclosure Certification (Master Contracts Only - See Exhibit G for Services-As-Needed Contracts) Attachment 1: Certification Regarding Lobbying – Certification form Attachment 2: Certification Regarding Lobbying – Disclosure form Exhibit A-3: SUD Qualified Service Organization Agreement (Master Contracts Only - See Exhibit H for Services-As-Needed Contracts) Exhibit A – Program Requirements/Scopes of Work (Exhibit A-P/SOWs) for Mental Health Contracts Exhibit A-P: Adult Outpatient Therapy Exhibit A-P: CalWORKs Exhibit A-P: Child Level I Exhibit A-P: Child/Youth Outpatient Exhibit A-P: Crisis Residential Exhibit A-P: Custom Exhibit A-P: Eating Disorder Exhibit A-P: Family Partner Exhibit A-P: FSP – Transition-Age Youth, Adult and Older Adult Exhibit A-P: Full Service Partnership (FSP) – Child Exhibit A-P: Housing Navigation Exhibit A-P: Housing Support Program (HSP) Exhibit A-P: In-Home Outreach Team (IHOT) Exhibit A-P: Integrated Behavioral Health Care Coordination (IBH) Exhibit A-P: Interim Housing Exhibit A-P: Individual Placement and Support (IPS) Exhibit A-P: Katie A., ICC and IHBS Exhibit A-P: Language ACCESS Exhibit A-P: Permanent Supportive Housing (PSH) Exhibit A-P: Promoting Access to Health (PATH) Exhibit A-P: School-Based Behavioral Health (SBBH) Exhibit A-P: Service Team Exhibit A-P: Short-Term Residential Therapeutic Program (STRTP) Exhibit A-P: Substitute Payee Exhibit A-P: Therapeutic Behavioral Services (TBS) Exhibit A-P: Underserved Ethnic and Language Populations (UELP) Exhibit A-P: Wellness Centers Exhibit A – Program Requirements (Exhibit A-P/SOWs) for Substance Use Disorder (SUD) Contracts Exhibit A-P: Opioid Treatment Exhibit A-P: Outpatient and Intensive Outpatient Treatment Exhibit A-P: Primary Prevention (Older Adult) Exhibit A-P: Primary Prevention (Youth) Exhibit A-P: Recovery Residence Exhibit A-P: Residential Treatment Exhibit B: Terms and Conditions of Payment Master MH Exhibit B: Terms and Conditions of Payment SAN MH FSP Exhibit B: – Coming Soon SAN HSP Exhibit B: – Coming Soon SAN MH Exhibit B: (No Data) – Coming Soon SAN MH Exhibit B: – Coming Soon Master SUD Exhibit B: Terms and Conditions of Payment SAN Opioid Treatment Exhibit B: Terms and Conditions of Payment – Coming Soon Standard Exhibit and Reference Only Standard Exhibit C: Insurance Requirements Exhibit C-2C: Insurance Requirements – No cash advance Exhibit C-4: Insurance Requirements – Cash advance Other Exhibits Exhibit D: Audit Requirements Exhibit E: Business Associate Provisions (HIPAA) Exhibit F: Debarment and Suspension Certification Exhibit G: Lobbying Restrictions and Disclosure Certification (Services-As-Needed Contracts Only - See Exhibit A-2 for Master Contracts) Attachment 1: Certification Regarding Lobbying Attachment 2: Disclosure of Lobbying Activities Exhibit H: SUD Qualified Service Organization Agreement (Services-As-Needed Contracts Only - See Exhibit A-3 for Master Contracts) Exhibit O: The Iran Contract Act (ICA) of 2010 Reference Only Master Contract Boilerplate Master Contract Amendment Coversheet Standard Documents for FY 22-23 Exhibit A Attachments Exhibit A: Table of Contents (Template) Exhibit A-1: Standard Requirements for Mental Health (MH) Contracts Exhibit A-1: Standard Requirements for Substance Use Disorder (SUD) Contracts Exhibit A-2: CBO Lobbying Restrictions & Disclosure Certification (Master Contracts Only - See Exhibit G for Services-As-Needed Contracts) Attachment 1: Certification Regarding Lobbying – Certification form Attachment 2: Certification Regarding Lobbying – Disclosure form Exhibit A-3: SUD Qualified Service Organization Agreement (Master Contracts Only - See Exhibit H for Services-As-Needed Contracts) Exhibit A – Program Requirements (Exhibit A-P) for Mental Health Contracts Exhibit A-P: Adult Outpatient Therapy Exhibit A-P: CalWORKs Exhibit A-P: Child Level I Exhibit A-P: Child/Youth Outpatient Exhibit A-P: Counseling-Enriched Special Day Class (CESDC) Exhibit A-P: Crisis Residential Exhibit A-P: Custom Exhibit A-P: Eating Disorder Exhibit A-P: Family Partner Exhibit A-P: FSP – Transition-Age Youth, Adult and Older Adult Exhibit A-P: Full Service Partnership (FSP) – Child Exhibit A-P: Housing Navigation Exhibit A-P: Housing Support Program (HSP) Exhibit A-P: In-Home Outreach Team (IHOT) Exhibit A-P: Integrated Behavioral Health Care Coordination (IBH) Exhibit A-P: Interim Housing Exhibit A-P: IPS Exhibit A-P: Katie A., ICC and IHBS Exhibit A-P: Language ACCESS Exhibit A-P: Permanent Supportive Housing (PSH) Exhibit A-P: Promoting Access to Health (PATH) Exhibit A-P: School-Based Behavioral Health (SBBH) Exhibit A-P: Service Team Exhibit A-P: Short-Term Residential Therapeutic Program (STRTP) Exhibit A-P: Substitute Payee Exhibit A-P: Therapeutic Behavioral Services (TBS) Exhibit A-P: Underserved Ethnic and Language Populations (UELP) Exhibit A-P: Wellness Centers Exhibit A – Program Requirements (Exhibit A-P) for Substance Use Disorder (SUD) Contracts Exhibit A-P: Opioid Treatment Exhibit A-P: Outpatient and Intensive Outpatient Treatment Exhibit A-P: Primary Prevention (Older Adult) Exhibit A-P: Primary Prevention (Youth) Exhibit A-P: Recovery Residence Exhibit A-P: Residential Treatment Exhibit B: Payment Terms and Conditions MH Exhibit B: Terms and Conditions of Payment MH FSP Exhibit B: Terms and Conditions of Payment SAN HSP Exhibit B: Terms and Conditions of Payment SAN MH Exhibit B: (No Data) Terms and Conditions of Payment SAN MH Exhibit B: (with Data) Terms and Conditions of Payment SUD Exhibit B: Terms and Conditions of Payment Mental Health Housing/Homeless Criteria and Definition of Terms EveryOne Home Alameda County Continuum of Care (CoC) Council Prioritization for Permanent Supportive Housing Opportunities Shift of Funds Request Educationally Related Mental Health Services Information Sheet School Based Behavioral Health Information Sheet SBBH Shift of Funds Application Family Engagement and Group Services Reminder Provider Resources Psychological Testing - Policy & Procedure 3/24/2021 MHP FFS Provider Forms MHP FFS Provider Handbook MHP FFS Provider Handbook Appendices Provider Update Form (Form No. 50-02) – Use this form to updated BHCS of changes such as: your location/address email, phone, or fax name a change to status with any licensing/oversight board that may impact your ability to provide, claim or be reimbursed for specialty mental health services Voluntary Disenrollment Form (Form No. 50-03) – Use this form to voluntarily dis-enroll from the MHP Provider Network FAQs Substance Use Disorder Coming soon Standard Organizational and/or Program Changes Forms Program and Provider Changes Process Provider/Program Change Notification Form – Use this for the process described as "A" – changes that do not require ACBH approval Program Change Request Form - Use this for the process described as "B" - changes that require prior ACBH approval Other Standard Forms Cash Advance Policy Cash Advance Form CBO Signature Authorization Form Sample CBO Signature Authorization Form Providers Contact Information