Mental Health, Alcohol and Other Drug Prevention & Treatment Services

Mental Health, Alcohol and Other Drug Prevention & Treatment Services

REQUEST FOR INFORMATION

FY 2012 NON-MEDICAID FUNDING

MENTAL HEALTH, ALCOHOL AND OTHER DRUG PREVENTION & TREATMENT SERVICES

FACE SHEET

Original / Revision / Date Submitted:
PROVIDER INFORMATION
Agency Name:
Address:
Telephone #: / Fax #:
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) #:

AUTHORIZATION

I hereby certify by my signature that this RFI has been approved for submission by this Agency’s governing authority.

Board President / Chair / Date / Executive Director / CEO / Date
ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist
(revised 2.1.11) Page 1 of 5 / Page 1 of 5
Agency Name:
Current Accreditations and Certifications & Expiration Dates: (check all that apply)
ODADAS Certification
Expiration Date / Expiration Date / Expiration Date
JCAHO / Outpatient / Residential
CARF / Intensive Outpatient / Detox
COA / Opioid Agonist / DIP
Other / Prevention
ODMH Certification
Expiration Date / Expiration Date
Crisis Intervention / Pharm Manag
MH Assessment / Detox
BH Counseling / CPST
ACT / Consultation
Prevention / Referral/Info
Consumer Operated / Other MH
MH Education / Other MH
Employment/Voc / Other MH
Other MH
Other MH
Other MH
Other MH
Agency Name:
AOD Services Requested for SFY 2012Non-Medicaid Funding Consideration: (check all that apply)

AoD Services

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
Agency Name:

Mental Health ServicesRequested for SFY 2012Non-Medicaid Funding Consideration: (check all that apply)

MH Services

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______
ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist
(revised 2.1.11) Page 1 of 5 / Page 1 of 5

REQUEST FOR INFORMATION

FY 2012 NON-MEDICAID FUNDING

ALCOHOL AND OTHER DRUG AND MENTAL HEALTH TREATMENT SERVICES

SUBMISSION & ORDER OF DOCUMENTS RFI CHECKLIST

(agency name)

Submission Deadline: 4:00 PM on Wednesday, March 2, 2011

NOTE: RFI packets delivered after the deadline will not be considered

and returned to the sender.

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)

COMPLETED CHECKLIST MUST BE SUBMITTED

BEHIND FACE SHEET OF RFI PACKET

ADAMHS Board of Cuyahoga County SFY 2012 Non-Medicaid Funding RFI Face Sheet/Checklist
(revised 2.1.11) Page 1 of 5 / Page 1 of 5