OHA/DHS Shared Services Production Region
|[pic] |Provider Agreement for |
| |Enhanced Care Outreach |
| |Services Program (ECOS) |
This form is to be completed electronically by Aging and people with disabilities (APD) or Area Agencies on Aging (AAA) case manager or transition coordinator following notification of ECOS enrollment and at yearly renewal of Client Assessment and Planning System (CAPS) Assessment. Email completed form to: Specific-Needs.Contract-Team@dhsoha.state.or.us
|Case information: All fields must be completed prior to submission |
|Resident’s name: | |
|Medicaid prime number: | |CAPS end date: |DD/MM/YYYY |
|*TC’s or CM’s name: | |Phone: | |
|Email: | |County of services: | |
|Start date ECOS enrollment or rate adjustment request: |DD/MM/YYYY | |
|Choose one: | |New ECOS services | |CAPS renewal |
|APD Licensed Provider information |
|Facility business name: | |
|Facility type: | |Provider number: | |
| |Enhanced Care Outreach Services program expectations have been reviewed |
| |with APD licensed provider, and provider agrees to the following: |
| |Participate in quarterly team meetings with the Community Mental Health Provider (CMHP), APD case manager and resident to review the behavioral health treatment |
| |plan and align the service plan. |
| |Participate in quarterly behavioral health trainings offered by the CMHP. |
| |Understand ECOS services are contingent upon the resident participation |
| |in and benefit from mental health treatment, as determined by the CMHP. |
| | |
|Payment instructions |
Once the 512 payment has been set up, email this form to: APD.Admissions@state.or.us
In the email subject line, type “ECOS rate request”. TC or CM will receive an email back stating that the ECOS rate has been added or renewed and instructions to “touch” the 512, pulling over the correct rate.
|Central office review |
|DHS Central Office adjustment of the service rate to the ECOS rate associated |
|with the facility type. |
|Rate adjusted: Completed |End date of rate adjustment: |MM/DD/YYYY |
|* TC is for transition manager and CM is case manager. |
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.