General Instructions Page 1 Application Face Sheet – The Application Face Sheet provides the SCO’s identifying information and serves as the cover sheet for submitting the required qualification documents to . Face Sheet Items: Organization’s Legal Entity Name the legally incorporated name of the SCO. – Address and Phone Number the SCO’s complete administrative office mailing – address, including the nine-digit zip code, and the phone number for the administrative office. Master Provider Index (MPI) and National Provider Identifier (NPI) Numbers Federal Employer Identification Number (FEIN) County (ies) where the organization currently provides s Coordination services please – list. County (ies) where you would like to provide services in the future may also be listed. Any other state office that the organization currently provides Supports Coordination services please answer Yes or No and list the offices that you provide service to. – Contact person Please designate one contact for the SCO, provide that person’s – email address, and ensure that that person coordinates the preparation, review and submission of all required documents associated with the Application. Executive Director and Board President the name, title, signature and date are – required for both positions. Non-governmental entities should provide the names and signatures of the SCO Executive and the President of the SCO’s governing board. Governmental entities should provide: as the Executive”, the name and signature of: “SCO The county MH/MR Administrator or the Services Director; and in lieu of the chair of its governing board, the name and signature of the or the Chair of the or the Chair of the County Council.
General Instructions Page 1 – Application Face Sheet The Application Face Sheet provides the SCO’s identifying information and serves as the cover sheet for submitting the required qualification documents to . Face Sheet Items: Organization’s Legal Entity Name – the legally incorporated name of the SCO. Address and Phone Number – the SCO’s complete administrative office mailing address, including the nine-digit zip code, and the phone number for the administrative office. Master Provider Index (MPI) and National Provider Identifier (NPI) Numbers Federal Employer Identification Number (FEIN) County (ies) where the organization currently provides s Coordination services – please list. County (ies) where you would like to provide services in the future may also be listed. Any other state office that the organization currently provides Supports Coordination services – please answer Yes or No and list the offices that you provide service to. Contact person – Please designate one contact for the SCO, provide that person’s email address, and ensure that that person coordinates the preparation, review and submission of all required documents associated with the Application. Executive Director and Board President – the name, title, signature and date are required for both positions. Non-governmental entities should provide the names and signatures of the SCO Executive and the President of the SCO’s governing board. Governmental entities should provide: as the “SCO Executive”, the name and signature of: The county MH/MR Administrator or the Services Director; and in lieu of the chair of its governing board, the name and signature of the or the Chair of the or the Chair of the County Council.
Initial+SCO+Qualification+Instructions+2017.docx