<p> REQUEST FOR INFORMATION </p><p>FY 2012 NON-MEDICAID FUNDING MENTAL HEALTH, ALCOHOL AND OTHER DRUG PREVENTION & TREATMENT SERVICES </p><p>FACE SHEET</p><p>Original Revision Date Submitted: </p><p>PROVIDER INFORMATION Agency Name: Address: Telephone #: Fax #: </p><p>Agency Web-site Address: Executive Director/CEO: E-mail Address: Fiscal Officer: E-mail Address: Clinical Director: E-mail Address: Board President/Chair: E-mail Address: Statutory Agent on file with Ohio Secretary of State: Federal Tax ID (EIN) #: </p><p>AUTHORIZATION</p><p>I hereby certify by my signature that this RFI has been approved for submission by this Agency’s governing authority.</p><p>Board President / Chair Date Executive Director / CEO Date</p><p>ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 1 of 6 (revised 2.1.11) Page 1 of ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 2 of 6 (revised 2.1.11) Page 2 of Agency Name: </p><p>Current Accreditations and Certifications & Expiration Dates: (check all that apply) ODADAS Certification Expiration Date Expiration Date Expiration Date</p><p>JCAHO Outpatient Residential </p><p>CARF Intensive Outpatient Detox </p><p>COA Opioid Agonist DIP </p><p>Other Prevention </p><p>ODMH Certification Expiration Date Expiration Date</p><p>Crisis Intervention Pharm Manag </p><p>MH Assessment Detox </p><p>BH Counseling CPST </p><p>ACT Consultation </p><p>Prevention Referral/Info </p><p>Consumer Operated Other MH </p><p>MH Education Other MH </p><p>Employment/Voc Other MH </p><p>Other MH </p><p>Other MH </p><p>Other MH </p><p>Other MH </p><p>ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 3 of 6 (revised 2.1.11) Page 3 of Agency Name: </p><p>AOD Services Requested for SFY 2012 Non-Medicaid Funding Consideration: (check all that apply)</p><p>AoD Services</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>ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 4 of 6 (revised 2.1.11) Page 4 of Agency Name: </p><p>Mental Health Services Requested for SFY 2012 Non-Medicaid Funding Consideration: (check all that apply)</p><p>MH Services</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>ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 5 of 6 (revised 2.1.11) Page 5 of REQUEST FOR INFORMATION </p><p>FY 2012 NON-MEDICAID FUNDING ALCOHOL AND OTHER DRUG AND MENTAL HEALTH TREATMENT SERVICES </p><p>SUBMISSION & ORDER OF DOCUMENTS RFI CHECKLIST</p><p>(agency name)</p><p>Submission Deadline: 4:00 PM on Wednesday, March 2, 2011</p><p>NOTE: RFI packets delivered after the deadline will not be considered and returned to the sender.</p><p>1. Face Sheet (signed by Executive Director/CEO & Agency Board President/Chair) 2. Completed Checklist 3. Agency Mission and Vision Statements 4. Copies of Proof of Liability Insurance 5. Original RFI (with original signatures throughout) & Nine Copies (total of ten) 6. Logic Model 7. CD with Submitted Documents (Word & Excel in PC format)</p><p>COMPLETED CHECKLIST MUST BE SUBMITTED BEHIND FACE SHEET OF RFI PACKET</p><p>ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist Page 6 of 6 (revised 2.1.11) Page 6 of </p>