Individual Enrollment And

ATR Network Part 5 Individual Enrollment and Attestation Forms

Instructions Part 5: Instructions – Individual ATR Enrollment and Attestation Form

Individual Enrollment Form: Complete the individual enrollment form for every individual providing an ATR service to clients. Complete the checklist of services the individual is qualified and/or licensed for and can provide to ATR clients.

Include credential information for each individual who will provide services to ATR clients, if their profession so requires. A copy of each individual’s license, certification, or registration must be provided with the enrollment (only if applicable: many recovery support providers do not have formal credentials). Individuals providing clinical treatment and/or recovery support must fill out this form.

Note: “Clinical Treatment Provider is defined as someone providing services listed under the “Clinical Treatment Services” ATR Care Categories.

“Recovery Support Provider” is defined as someone providing services under the “Recovery Support” ATR Care Categories.

Individual Attestation Form: Every individual person having ATR client contact must sign and date an attestation statement. Clinical Treatment and Recovery Support attestation forms are different. An individual may provide both Clinical Treatment and Recovery Support services: in that case, BOTH attestation forms should be completed and sent with the application.

Background Check Policy: Every individual providing a direct client service must have a criminal background check completed within the 12 months prior to the date of their initial application. The individual, tribe or organization must certify that no individual who has been found guilty of, or entered a plea of nolo contendere or guilty to any felonious offense, or any of two or more misdemeanor offenses, under Federal, State, or tribal law involving crimes of violence; sexual assault, molestation, exploitation, contact or prostitution; crimes against persons; or offenses committed against children has been approved as an ATR provider under their administrative umbrella. This is in compliance with the Indian Child Protection and Family Violence Protection Act, Sec. 3207, Character investigations. (ATR Guideline Section 1, Number 7). After the initial approval, background checks will stay in effect for the term of the Access to Recovery Initiative and will not need to be repeated. If an individual ATR provider is convicted of a crime during this period it is the provider’s responsibility to notify the tribe or organization about the conviction. It is the tribe or organization’s responsibility to notify ITC/ATR about the conviction. Failure to notify will result in the individual’s immediate termination as an ATR provider..

Anishnaabek Healing Circle ATR ATR Provider Application Page 1 2010 (04-22-16) Part 5: Individual Enrollment & Attestation Form Anishnaabek Healing Circle ATR Individual Enrollment Form Part 5

Make a copy of this form for each individual person who will provide a service to ATR clients.

1. Name ______2. Position/Title ______

3. Education & Specialty Area______

4. Work Email______5. Work Telephone Number: ______

6. Physical Location/Site Where Person provides ATR services: ______

______Zip Code: ______

7. Name of Business/Organization/Tribe: ______

Name of Department or Program if under a Tribal Umbrella: ______

8. Identify the program, department or circumstance under which you provide ATR services:

(Check one in this section) o Tier 2, Organization (self-billing) o Tier 1, Tribal Organization (billed for by o Tier 2, Independent Individual Tribe) Provider(s) (self-billing) o Tier 1, Provider under a Tribal Umbrella (billed for by Tribe) ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~ (Check one: primary ATR function) Behavioral Health o Substance Abuse Counselor o Alternative Therapies Provider o Mental Health Counselor/Therapist Non-Behavioral Health Programs o Co-Occurring Counselor o Counselor o Family Therapist o Clinician, Therapist o Psychologist o Case manager, Care Coordinator o Psychiatrist o Other: ______o Case Manager, Care Coordinator Education o Prevention Specialist o Trainer/ teacher o Helping Healer o Group Facilitator Health Cultural/Spiritual o Primary Health Care Provider o Cultural. Community Resource Person o Community Health Representative o Spiritual Support Resource Person (CHR) Recovery Resources o Community Health Education o Recovery Coach/Peer Specialist/Provider o Recovery Coach/ non-Peer o Health and Fitness Specialist o Recovery Community Resource Person

Anishnaabek Healing Circle ATR ATR Provider Application Page 2 2010 (04-22-16) Part 5: Individual Enrollment & Attestation Form o Other: ______

Anishnaabek Healing Circle ATR ATR Provider Application Page 3 2010 (04-22-16) Part 5: Individual Enrollment & Attestation Form ~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

(Check one in this section) o Employee of a tribe/ organization or program o Volunteer for a tribe/ organization or program o Contractor for a tribe/ organization or program o Independent Individual Provider

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

9. Highest Level of Education (check one): o No college degree o Registered Nurse (RN) o Associate degree o Licensed Practical Nurse (LPN) o Bachelor degree o Nurse Practitioner (NP) o Masters degree (other than MSW) o Physicians Assistant (PA) o Masters of Social Work o Traditional Practitioner o Ph.D. o Other : ______o Medical Doctor

10. Substance Abuse Certification: MCBAP o CPC-R: Certified Prevention Consultant o CADC-M: Certified Addiction Counselor MI o CCJP: Certified Criminal Justice Professional (non-reciprocal) o CCDP: Certified Co-Occurring Disorders o CAADC: Certified Advanced Addiction Professional Counselor o CCDP-D: Certified Co-Occurring Disorders o CADC – Certified Alcohol & Drug Counselor Professional – Diplomate o CAC-R: Certified Clinical Supervisor – IC&RC Reciprocal UMICAD: Certified Alcohol & Drug Counselor o CCS – Certified Clinical Supervisor o CADC Level I: o CPS – Certified Prevention Specialist – IC& RC o CADC Level II Reciprocal o CADC Level III

Complete this portion for a person providing services under a license, registration or certification for their profession and/or specialty area:

Type of Certification or License: ______11. License/Certification Board Name: ______12. License/Certification Number: ______13. License/Certification Dates (Effective) ______(mm/dd/yy) (Expiration) ______(mm/dd/yy)

For ITC Office Use Only: This person is approved as an ATR

___ Clinical Treatment Provider ___ Recovery Support Provider ___ Both

Anishnaabek Healing Circle ATR ATR Provider Application Page 4 2010 (7-22-13) Updated Part 5: Individual Enrollment & Attestation Form Services the individual is qualified and/or licensed and can provide to ATR clients: o F a m Check all that apply i l Anishnaabek Healing Circle y Therapy w/ Client (2092) ATR CARE CATEGORIES o HIV/AIDS Counseling (2120) o Other Clinical Services (2130) Intensive Outpatient o Clinical Treatment Plan (2060) Clinical Treatment Services o Individual Counseling (2070) Access Center o Group Counseling (2080) o Screening (2010) o Family/Marriage Counseling (2090) o Clinical Assessment (2011) o Family Therapy w/o Client (2091) o Recovery Support Assessment (2012) o Family Therapy w/ Client (2092) o GPRA Intake (2013) o HIV/AIDS Counseling (2120) o ATR Intake Interview (2016) o Other Clinical Services (2130) o Recovery Management Plan (2061) Non-Hospital Residential Treatment Client GPRA Follow-up o ATR Network Approved Provider ( list of (2015, 2018, 2021, 2022, 2023) codes) o GPRA 6 month Follow-up Sub-Acute Detox Client GPRA Discharge (2014, 2017) o ATR Network Approved Provider o GPRA Discharge (list codes) Note: Only a Tribal Access & Care Mental Health/Co-occurring Treatment Coordination Center can provide the o Co-occurring Treatment/ Recovery Services services listed above. (2100) o Psychological Testing (2101) Motivational Development & Readiness o Psychiatric Evaluation & Follow-up (2102) o Substance Abuse Education (6010) o Other Co-occurring Treatment (2104) o Motivational Development Activities (6038) Medical Services (excludes mental health, Care Coordination psychiatric, substance abuse) o Individual Services Coordination (3040) o Medical Care (4010) o Report & Record Keeping (3042) o Alcohol & Drug Testing (4020) o Crisis Intervention (2131) o HIV/AIDS Medical Support & Testing o Discharge Planning for Clinical TX (2132) (4030) o Other Aftercare Services (5060) o Other Medical Services (4040) o Continuing Care (5010) Transitional Living Facilities Transitional, Sober Housing, Approved o Information & Referral (7040) o Brief Intervention ATR Network Provider (list codes) o Brief Intervention (2020) Outpatient o Clinical Treatment Plan (2060) Recovery Support Services o Individual Counseling (2070) Housing Support Services (3070, 7020) o Group Counseling (2080) Examples: o Family/ Marriage Counseling (2090) o Stable Living Environment o Family Therapy w/o Client (2091) o Stable Recovery Environment

Anishnaabek Healing Circle ATR ATR Provider Application Page 5 2010 (7-22-13) Updated Part 5: Individual Enrollment & Attestation Form o Safe Living Environment o Nutritional Management (4045) o Emergency or Temporary Housing o Stress Management (4046) o Eviction Assistance, Barrier Mitigation o Massage Therapy (4047) Employment and Education o Employment Services (3030) o Pre-Employment (3031) Spiritual and Cultural Support o Employment Coaching (3032) o Individual Spiritual Support (5050) o Daily Living Skills Group (6035) o Traditional Healing Services (5051) o Daily Living Skills & Cultural Subsistence o Sweat Lodge (5052) Materials Support (6037) o Talking Circle (5053) o Other Education Services Group (6030) o Spiritual/Cultural Feast Supplies (5054) Peer Support and Relapse Prevention o Spiritual/Cultural Retreat Support (5055) o Peer Coaching or Mentoring (7010) o Sweat Lodge Materials (5056) o Other Peer-to-Peer Recovery Support o Indigenous Language Expression (6031) Services (7050) o Storytelling, Cultural Teaching Group o Self Help & Support Groups (5040) (6032) o Alcohol & Drug-free Social Activities o Tribal Song & Dance Group (6033) (7030) o Tribal Arts & Crafts Group (6034) o Individual Recovery Coaching (5030) o Daily Living Skills & Cultural Subsistence o Individual Relapse Prevention (5020) Materials Support (6037) o Group Relapse Prevention (5021) Transportation (5030) Family and Parenting Support Examples: o Family Services (3010) o Public & Private Transportation o Child Care (3020) o Drivers License Reinstatement o Domestic Violence Group (3033) o Other Transportation Needs Financial – Basic Needs o Special Needs Fund (3081) Legal Support (3082) Briefly explain details of your recovery support Examples: service provision: do you work with o Court, Corrections, Probation individuals, groups, families; what are some of o Legal Issues, Advocacy the details/special qualities of your service; o Other ______why/how can your service help an individual Health and Global Wellness attain and then maintain a recovery-oriented o HIV/AIDS Education Group (6020) lifestyle? ______o Acupuncture (4041) ______Auricular Acupuncture (4042) o ______o Alternative Therapies (4043) ______(list)______o Physical Fitness & Well-Being Activities Specialty services your program provides: (4044) ______(list)______

Anishnaabek Healing Circle ATR ATR Provider Application Page 6 2010 (7-22-13) Updated Part 5: Individual Enrollment & Attestation Form Individual Attestation Questions Clinical Treatment Personnel

Must be completed, signed, and dated by each individual providing CLINICAL TREATMENT SERVICES (Services listed under the “Clinical Treatment” Care Categories)

Each individual/ staff member/ service provider is required to complete, sign, and date this form. For programs that have more than one person providing services, please make a copy of this form for each staff person. An application will not be considered complete unless a completed attestation question form is submitted for each person who is identified to provide clinical treatment services to ATR clients.

Please answer “YES” or “NO” to the questions below. If you answer “YES” to questions A through K, or if you answer “NO” to question L, please provide a full explanation on a separate sheet of paper referencing the section number.

A. Has your license, registration, or certification to practice in any jurisdiction ever been denied, limited, restricted, suspended, revoked, not renewed, or subject to probationary conditions, or have you voluntarily or involuntarily relinquished any such license, registration, or certification or voluntarily or involuntarily accepted any such actions or conditions, or have been fined or received a letter of reprimand or is such action pending? ___Yes ___No

B. Have you ever been charged, suspended, fined, disciplined, or otherwise sanctioned, subject to probationary conditions, restricted or excluded, or have you voluntarily or involuntarily relinquished eligibility to provide services or accepted conditions on your eligibility to provide services, for reasons relating to possible incompetence or improper professional conduct, or breach of contract or program conditions, by Medicare, Medicaid, or any other public program, or is any such action pending? ___Yes ___No

C. Have your clinical privileges, membership, contractual participation or employment by any medical organization (e.g., hospital medical staff, medical group, independent practice association [IPA], health plan, health maintenance organization [HMO], preferred provider organization [PPO], medical society, professional association, medical school faculty possession, or other health delivery entity or system), ever been denied, suspended, restricted, reduced, subject to probationary conditions, revoked or not renewed for possible incompetence, improper professional conduct, or breach of contract, or is any such action pending? ___Yes ___No

D. Have you ever surrendered, allowed to expire, voluntarily or involuntarily withdrawn a request for membership or clinical privileges, terminated contractual participation or employment, or resigned from any medical organization (e.g., hospital medical staff, medical group, independent practice association [IPA], health plan, health maintenance organization [HMO], preferred provider organization [PPO], medical society, professional association, medical school faculty position, or other health delivery entity or system) while under investigation for possible incompetence, improper professional conduct, or breach of contract, or in return for such an investigation not being conducted, or is any such action pending? ___Yes ___No

Anishnaabek Healing Circle ATR ATR Provider Application Page 7 2010 (7-22-13) Updated Part 5: Individual Enrollment & Attestation Form E. Have you ever surrendered, voluntarily withdrawn, or been requested or compelled to relinquish your status as a student in good standing in any internship, residency, fellowship, or other clinical education program? ___Yes ___No

F. Has your membership or fellowship in any local, county, state, regional, national, or international professional organization ever been revoked, denied, reduced, limited, subjected to probationary conditions, or not renewed, or is any such action pending? ___Yes ___No

G. Have you ever been denied certification/recertification by a specialty board, or has your eligibility, certification or recertification status changed (other than changing from eligible to certified)? ___Yes ___No

H. Have you ever been convicted of any crime (other than a minor traffic violation)? ___Yes ___No If yes, give particulars on a separate sheet of paper.

I. Do you presently use any drugs illegally? ___Yes ___No

J. Have any judgments been entered against you, or settlements been agreed to by you within the last seven (7) years, in professional liability cases, or are there any filed and served professional liability lawsuits/arbitrations against you pending? ___Yes ___No

K. Has your professional liability insurance ever been terminated, not renewed, restricted, or modified (e.g., reduced limits, restricted coverage, surcharged), or have you ever been denied professional liability insurance, or has any professional liability carrier provided you with a written notice of any intent to deny, cancel, renew, or limit your professional liability insurance or its coverage of any procedures? ___Yes ___No

L. Are you able to perform all of the services required by your agreement with, or the professional staff bylaws of the health organization to which you are applying, with or without reasonable accommodation, according to accepted standards of professional performance standards and without posing a direct threat to the safety of clients? ___Yes ___No

M. Have you had a criminal background check within the last 12 months? ___Yes ___No Is it on file with your organization or agency? ___Yes ___No Are you currently an ATR approved provider? ____yes ____No (use for staff change of status)

I hereby affirm that the information submitted in this Part 3 – Individual Attestation Questions, and any attached addendums is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that omissions and misrepresentations may result in denial of my application or termination of my privileges as a provider under ATR.

______Name (Print)

______Name (Signature) Date

Provide a copy of credential information or license for each person, if applicable.

Anishnaabek Healing Circle ATR ATR Provider Application Page 8 2010 (7-22-13) Updated Part 5: Individual Enrollment & Attestation Form Individual Attestation Questions Recovery Support Personnel

Must be completed, signed, and dated by each individual or staff person providing RECOVERY SUPPORT SERVICES (Services other than those listed under the “Clinical Treatment” Care Categories)

Each individual/ staff person/ service provider is required to complete, sign, and date this form. An application will not be considered complete unless a completed attestation question form is submitted for each person who is identified to provide services to ATR clients.

Please answer “YES” or “NO” to the questions below. If you answer “YES” to questions A through C, please provide a full explanation on a separate sheet of paper referencing the section number.

Have you ever been convicted of any crime (other than a minor traffic violation)? ___Yes ___No If yes, give particulars on a separate sheet of paper.

Do you presently use any drugs illegally? ___Yes ___No

C. Have you had a criminal background check within the last 12 months? ___Yes ___No Is it on file with your organization or agency and/or available for audit? ___Yes ___No Are you currently an ATR approved provider? ____yes ____No (use for staff change of status)

I hereby affirm that the information submitted in this Section (Individual Attestation Questions) and any attached addendums is true, current, correct, and complete to the best of my knowledge and belief and is furnished in good faith. I understand that omissions and misrepresentations may result in denial of my application or termination of my privileges as a provider under ATR.

______Print Name

______Signature Date

Provide a copy of credential information or license for each person, if applicable.

Anishnaabek Healing Circle ATR ATR Provider Application Page 9 2010 (7-22-13) Updated Part 5: Individual Enrollment & Attestation Form