RFP #0918-008 Residential Treatment Level III Specialty Focus on Problem Sexual Behavior Title Page (counts as 1 page) Please complete the following information: Name of Organization: Organization Type: Hospital Private Organization: not for profit for profit Governmental/Public Facility License Number (If Applicable): Accreditation Type and Source: Primary Client Adults Adolescents Children All ages Population: Mailing Address: Street, City and Zip Code Facility Location Street, City and Zip Code Address: Name of Contact Person: Contact Person Phone # & Email: Please list other MCOs, with whom you have contracts: Please list other MCOs, with whom you are credentialed: Please indicate in Burke Catawba Cleveland Gaston which counties Iredell Lincoln Surry Yadkin services will be located: Provider Experience
RFP #0918-008 Residential Treatment Level III Specialty Focus on Problem Sexual Behavior Title Page (counts as 1 page) Please complete the following information: Name of Organization: Organization Type: Hospital Private Organization: not for profit for profit Governmental/Public Facility License Number (If Applicable): Accreditation Type and Source: Primary Client Population: Adults Adolescents Children All ages Mailing Address: Street, City and Zip Code Facility Location Address: Street, City and Zip Code Name of Contact Person: Contact Person Phone # & Email: Please list other MCOs, with whom you have contracts: Please list other MCOs, with whom you are credentialed: Please indicate in which counties services will be located: Burke Catawba Cleveland Gaston Iredell Lincoln Surry Yadkin Provider Experience
RFP_0918-008_Residential_Level_III_PSB_Narrative_Form.docx