<p> REQUEST FOR INFORMATION CY 2014 NON-MEDICAID FUNDING FACESHEET (Type directly in this document)</p><p>PROVIDER INFORMATION</p><p>Agency Name: </p><p>Address:</p><p>Contact Person</p><p>Telephone #: E-mail Address: </p><p>AUTHORIZATION I hereby certify that my typed name below is my signature and that this RFI has been approved for submission by this Agency’s governing authority.</p><p>Executive Director / CEO Date</p><p>Submission Deadline: 4:00 PM on Wednesday, September 11, 2013 Submit RFI Response by EMAIL to: [email protected]</p><p>Submissions received after the deadline will not be considered.</p><p>Note: In the event, your organization cannot submit electronically, hardcopy submissions will be considered. However, in order to receive a contract you will be expected to be able to operate electronically. Deliver hardcopy submissions to: William M. Denihan, Chief Executive Officer, Alcohol Drug Addiction and Mental Health Services Board of Cuyahoga County, 2012 West 25th, 6th Floor, Cleveland, Ohio 44113</p><p>RFI Checklist: Instructions for all check boxes on this Facesheet: Highlight box; right click; click properties & select check under default value; then click OK. </p><p>1. Face Sheet (signed by Executive Director/CEO) 2. Cuyahoga CY 2014 RFI Word Document (requesting program data) 3. CY 2014 Budget Document (Excel format) 4. Copy of Agency Service Plan</p><p>ADAMHSCC CY 2014 Non-Medicaid Funding RFI Face Sheet/Checklist (Rev 8.22.13) Page 1 of 2 AOD Services Requested for CY 2014 Non-Medicaid Funding Consideration: (check all that apply)</p><p>Acute Hospital Detoxification – H0009 Medical Community Residential Treatment – Hospital Setting – A1210 Ambulatory Detoxification – H0014 Medical Community Residential Treatment-Non-Hospital Setting – A0230 Assessment – H0001 Non-Medical Community Residential Treatment – A1220 Case Management – H0006 BH Medical Community Residential Treatment-Hospital Setting – H0017 Crisis Intervention – H0007 BH Medical Community Residential Treatment Non-Hospital Setting – H0018 Family Counseling – T1006 Non-Medical Community Residential Treatment – H0019 Group Counseling – H0005 Meals – T1010 BH Counseling & Therapy – H0004 Room & Board – A0740 Intensive Outpatient (IOP) – H0015 Consultation – A0560 Laboratory Urinalysis – H0003 BH Hotline – H0030 Medical/Somatic – H0016 Intervention – H0022 Methadone Administration – H0020 Referral and Information – A0510 Sub Acute Detoxification – H012 Training – H0021 23 Hour Observation Bed - 99236 Child Care – T1009 Urine Dip Screen – A0780 Transportation – A0750 Outreach – H0023 AoD Services not otherwise Classified – H0047 Information Dissemination – A0610 Education – A0620 Community Based Process – A0630 Environmental – A0640 Alternatives – A0660 Problem Identification & Referral – A0650</p><p>Mental Health Services Requested for CY2014 Non-Medicaid Funding Consideration:(check all that apply)</p><p>Crisis Intervention MH Services– S9484 Intensive Home Based Treatment (Non-Clinical) – M1810 Psychiatric Diagnostic Interview (Physician) - 90801 Assertive Community Treatment (Non-Clinical) – M1910 MH Assessment (Non-Physician) – H0031 Residential Care (Treatment & Support) – M2200 Pharmacological Mgt - 90862 Community Residence – M2240 BH Counseling & Therapy (Individual)– H0004 Foster Care – M2250 BH Counseling & Therapy (Group)– H0004 Subsidized Housing – M2260 Community Psychiatric Supportive Treatment(Individual) – H0036 Respite Care – M2270 Community Psychiatric Supportive Treatment(Group)– H0036 Crisis Care – M2280 Partial Hospitalization (less than 24hr)– S0201 Temporary Housing – M2290 BH Hotline – H0030 Consumer Operated Services – M3120 Intensive Home Based Treatment (Clinical) – H2016 Self-Help / Peer Support – H0038 Assertive Community Treatment (Clinical) – H0040 Information and Referral – M4130 Occupational Therapy – M1430 Other MH Services (Non-Healthcare) – M3140 Adjunctive Therapy – M1440 Other MH Services (Healthcare) – H0046 School Psychology – M1530 Prevention – M4110 Adult Education – M1540 Consultation – M4120 Social & Recreational – M1550 Mental Health Education – M4140 Employment/Vocational Services – M1620 Other______</p><p>ADAMHSCC CY 2014 Non-Medicaid Funding RFI Face Sheet/Checklist (Rev 8.22.13) Page 2 of 2</p>