<p> COMMUNITY LIVING SERVICES OF OAKLAND COUNTY CREDENTIALING AND QUALIFICATION PACKET</p><p>PURPOSE</p><p>Community Living Services of Oakland County, Inc. (CLS) is issuing this Credentialing and Qualification Packet to assure qualification for individuals wanting to be considered to provide services and supports to CLS enrollees. CLS does not refer or recommend any vendor who completes this Packet; the purpose of this packet is to review and document the qualifications and credentials of those wishing to provide services.</p><p>INSTRUCTIONS</p><p> Please respond to every section of this document.  Return completed document to:</p><p>Community Living Services 3270 Greenfield Road Berkley, Michigan 48072 Attention: Lisa Ballien</p><p>______Name of Individual Providing Service or Support</p><p>Independent Support Coordination Services ______Type of Service or Support </p><p>Person responsible for answering questions regarding information contained in this Packet.</p><p>Name Phone</p><p>1 CREDENTIALING AND QUALIFICATIONS Please attach a written response to each item listed below. CREDENTIALS 1. Attach a copy of your most current Social Work License and/or other professional license(s), as applicable. 2. Attach a copy of your transcript(s) and/or diploma. 3. Do you have current CPR and/or First Aid Training? (Please check one) YES ____ NO ____ If yes, please attach a copy of your current CPR and/or First Aid Training card(s). PHILOSOPHY AND ABILITY 1. Provide a statement of your intent/mission as a provider of Support Coordination Services. 2. Provide a copy of resume detailing your experience in working with people with developmental disabilities and their families. 3. Describe your commitment to and experience with Self-Determination. 4. Describe your commitment to and experience with Person Centered Planning. 5. Explain your commitment to and experience with Gentle Teaching. 6. Describe your philosophy/approach to service delivery and advocacy as related to persons with disabilities and their families. 7. Describe your plan to develop/nurture natural (unpaid) supports in people’s lives. 8. Describe how you anticipate linking people and their families with community based services and supports. 9. Attach a profile of yourself, brochure, or marketing material for us to share with other who may be interested in interviewing you as a potential Independent Support Coordinator. QUALITY ASSURANCE 10. Describe how you will assess satisfaction with the services you will be providing. 11. Describe how you will report information to us about satisfaction, trends observed, and changes made in your services. SERVICES AND FEES 12. Please provide a proposed fee schedule for your Supports Coordination services. GENERAL INFORMATION Name </p><p>Address</p><p>Phone Secondary Number Facsimile No. E-Mail Address Website Address You are organized as which of the following: ______DBA ____ Independent Contractor ____ Sole Proprietorship _____ Other (Please specify) ______Provide taxpayer Federal ID number or completed W-9 form or social security number (for payment purposes). ______ You must be able to show proof that you are eligible to work in the United States. You will be asked to complete an I-9 form prior to providing any service. RECIPIENT RIGHTS Do you have any substantiated rights violations against you? No _____ Yes _____  If yes, Attach a report detailing your history regarding all substantiated rights violations. I agree to accept, review, and follow all Recipient Rights Policies set forth and mandated by the Oakland County Community Mental Health Authority. ______Signature Date 2 CONFLICT OF INTEREST You must disclose any real or potential conflict of interest that exists in regard to your ability to provide supports coordination services to consumers of the Oakland County Community Mental Health Authority. This includes a description of any relationship to the Oakland County Community Mental Health Authority or any of its agents/agencies, component units/agencies, or oversight unity, together with a statement explaining why such relationships do not constitute a conflict of interest relative to providing Supports Coordination services. Do you have any real or potential conflicts of interest as described above? No _____ Yes _____ If yes, attach documentation requested above. LITIGATION REPORT Are you currently involved in any sort of legal dispute, claim, or lawsuit made against; or disputes, claims or lawsuits relating to care or services provided to any person? No_____ Yes______If yes, provide a list and status report on any such disputes, claims or lawsuits. Are you currently involved in any sort of legal dispute, claim, or lawsuit made against; or disputes, claims or lawsuits arising out of issues related to your fiscal management/solvency? No_____ Yes______If yes, provide a list and status report on any such disputes, claims or lawsuits. VERIFICATION OF INSURANCE  Attach your Declaration Face Sheet or Certificate of each type of insurance listed for which you have coverage. Check if attached or indicate “N/A” if you do not have that coverage because it is not applicable. Policies (As Applicable) General Liability Motor Vehicle Property Professional Liability Umbrella Other Workers’ Compensation Excess Liability LICENSING  Attach copies of any current license, certification, registration or accreditation.</p><p>1. Has your state license/certification ever been revoked, suspended, limited or placed on provisional status?  Yes No Not Applicable 2.Is action pending to revoke, suspend or limit your license/certification?  Yes No Not Applicable 3.Have you had any other certification/accreditation revoked, suspended or limited?  Yes No Not Applicable 4. Have you had any sanctions imposed by Medicare and/or Medicaid?  Yes No Not Applicable If yes was answered to any of the above questions, please provide the current status and details on a separate sheet. Please include the following:  Description of incident, including correspondence with state licensing boards.  A detailed description of any litigation, including settlements, court awards, etc. CRIMINAL BACKGROUND CHECK</p><p> Criminal background checks must be conducted annually for anyone who provides services to Community Living Services, Inc. Enrollees, including, but not limited to supports coordinators, clinicians, administrative staff, clerical staff and Executive Directors.</p><p> Please note, Community Living Services, Inc. will conduct a background check on you. Your signature on the attached Authorization to Release and Obtain Information document authorizes Community Living Services, Inc. to conduct this background check..</p><p>3 3270 Greenfield Road Berkley, MI 48072 Phone: 248-547-2668 Fax: 248-547-3052</p><p>AUTHORIZATION TO RELEASE AND OBTAIN INFORMATION</p><p>I understand that Community Living Services of Oakland County, Inc. (CLS) requires documentation of criminal history and if necessary for my position, my driving record, sex offender registry check, Family Independence Agency Protective Service Clearance, and status of my State of Michigan professional license/registration. I agree to provide the following information and authorize CLS to release that information to the State of Michigan to conduct the required background checks. (Please print the requested information below.)</p><p>Name: Last First Middle Date of Birth: Month Day Year</p><p>Race: Sex: Male Female</p><p>Social Security Number: Driver’s License #:</p><p>Alias or Maiden Name(s): State of Michigan License/Registration Type: ID#:</p><p>I understand that CLS will provide my identifying information to the State of Michigan to determine the status of my driving record, criminal history, and professional license/registration. As the authorized user, CLS obtains public information available through official State of Michigan on-line sources to assure the safety and security of persons served and employees. Should it become necessary to conduct a more detailed search for information that is not a matter of public record, CLS must have my prior, written authorization. Family Independence Agency Protective Service Clearances are handled by the local Family Independence Agency with separate, written consent. </p><p>Authorized user: Community Living Services of Oakland County, Inc. 3270 Greenfield Road Berkley, MI 48072</p><p>I acknowledge that this Authorization to Release and Obtain Information shall be in effect throughout the time that I provide supports for people supported by CLS. I acknowledge that CLS may conduct periodic reviews of my driving record, criminal history, and status of my professional license/registration on an on- going basis while I support CLS enrollees.</p><p>By signing below, I authorize CLS to release my identifying information to conduct Criminal Background Check and, if required for my position, Motor Vehicle Record Check, certification of my State of Michigan professional license/registration and Michigan Sex Offender Registry check.</p><p>Signature Date</p><p>4 OVERVIEW Name: Phone: Main Office Address: Satellite Office Address: How soon after being selected would you be available to begin the provision of services? ______Would you be available to provide emergency services? Yes ______No ______Do you have a plan for 24 hour on-call accessibility? Yes ______No ______If yes, explain: ______Do you conduct drug testing of your staff? Yes _____ No ______How often? ______Do you have experience or special expertise in supporting people with the following: [ ] Autism [ ] Limited English Proficiency [ ] Specific Cultural or Language (including [ ] Child Custody/Parenting Issues [ ] Mental Illness Sign language Needs (specify): [ ] Complex Medical Needs [ ] Mobility/Physical Issues [ ] Criminal History [ ] Pica Tracheotomy/Ventilator Dependency [ ] Dementia/Alzheimer’s [ ] Prader Willi Syndrome [ ] Visual Impairments [ ] Epilepsy/Seizure Disorder [ ] Recurrent Psychiatric Admissions [ ] Other: ______[ ] Geriatric/Aging Issues [ ] Sexual Deviance [ ] [ ] Hearing Impairments [ ] Substance Abuse History What do you consider to be your or your organization's strengths?</p><p>In what geographical areas are you able to provide supports? Circle the areas below. Holly Grove- Brandon Oxford Addison land Rose Spring- Indepen- Orion Oakland field dence High- White Water- Auburn Roch- land Lake ford Hills ester Hills Mil- Com- West Bloom- Troy ford merce Bloom- field field Lyon Novi Farming- South- Royal ton Hills field Oak</p><p>Additional information you would like to provide:</p><p>Contact Person to set up interviews: Phone Number: </p><p>Authorized Signature I hereby certify that the information contained in this document is true and correct to the best of my knowledge. Falsification of information in this document could result in removal from the Directory of Services and Supports and/or suspension and/or termination of funding through Community Living Services, Inc.</p><p>______Signature Date</p><p>5 REFERENCES</p><p>Please provide 3 references who have given permission to be contacted regarding your services. </p><p>Name: Relationship: </p><p>Address: </p><p>Phone: ( ) Fax: ( ) E-mail: </p><p>Description and date of supports and services provided:</p><p>Name: Relationship: </p><p>Address: </p><p>Phone: ( ) Fax: ( ) E-mail: </p><p>Description and date of supports and services provided:</p><p>Name: Relationship: </p><p>Address: </p><p>Phone: ( ) Fax: ( ) E-mail: </p><p>Description and date of supports and services provided:</p><p>6</p>