B Provider Survey FY 2017 Expected respondent: The Home and Community Based Waiver (HCBS) service Provider who has direct knowledge of the individual's day-to-day supports and/or the operational and administrative activities of the provider agency. Provide the respondent's contact information for further questions: Name: Position/Title: Contact Phone Number: Contact Email Address: Instructions: Provide a response to each question, taking into consideration the individual identified in the email. Do not provide any additional documentation separate from the completed survey. Responses to this survey and supporting information may be verified at a later date. Note: If you have general questions about completing the survey or need survey assistance, please contact your Pre-Paid Inpatient Health Plan (PIHP) Home and Community Based Service (HCBS) Lead Coordinator. Click on this link for a list of HCBS Coordinators: 71547_2943-334724--,00.html. If you have specific questions about the HCBS statewide transition process, the heightened scrutiny process, or the survey process, please email your questions to the Michigan Department of Health and Human Services Habilitation Supports Waiver Program at Name of Agency Address City State Postal code Email Address Contact Phone Number Is the agency licensed by the Michigan Department of Human Services, Bureau of Children and Adult Licensing (BCAL)? Yes No What is the Michigan Department of Human Services, Bureau of Children and Adult Licensing (BCAL) number? If BCAL number is not available, enter the National Provider Identification (NPI) Number or the Employer Identification Number (EIN).
B Provider Survey FY 2017 Expected respondent: The Home and Community Based Waiver (HCBS) service Provider who has direct knowledge of the individual's day-to-day supports and/or the operational and administrative activities of the provider agency. Provide the respondent's contact information for further questions: Name: Position/Title: Contact Phone Number: Contact Email Address: Instructions: Provide a response to each question, taking into consideration the individual identified in the email. Do not provide any additional documentation separate from the completed survey. Responses to this survey and supporting information may be verified at a later date. Note: If you have general questions about completing the survey or need survey assistance, please contact your Pre-Paid Inpatient Health Plan (PIHP) Home and Community Based Service (HCBS) Lead Coordinator. Click on this link for a list of HCBS Coordinators: 71547_2943-334724--,00.html. If you have specific questions about the HCBS statewide transition process, the heightened scrutiny process, or the survey process, please email your questions to the Michigan Department of Health and Human Services Habilitation Supports Waiver Program at Name of Agency Address City State Postal code Email Address Contact Phone Number Is the agency licensed by the Michigan Department of Human Services, Bureau of Children and Adult Licensing (BCAL)? Yes No What is the Michigan Department of Human Services, Bureau of Children and Adult Licensing (BCAL) number? If BCAL number is not available, enter the National Provider Identification (NPI) Number or the Employer Identification Number (EIN).
1915b3-hcbswaiver-word-provider-survey-08-02-2017.docx