FORM D: APPLICANT READINESS - Texas Health and Human ...



FORM D: APPLICANT READINESSThis section details the applicant’s readiness as it relates to project described in this OE. NOTE: Applicant must submit a separate and complete enrollment application and required documents for each clinic site.Applicant Organization NameRegionClinic Site / License InformationLicense NumberClinic’s Physical Address, City, & Zip CodeCountyState the number of slots that will be committed to HHSC for Committed CapacityAttach documentation of current facility licensure as a Outpatient Substance Use Disorder Provider. Date DSHS facility licensure was issued. NOTE: DSHS facility licensure must be held directly by your organization. Provide DATA 2000 Waiver for each prescribing Physician, prescribing Nurse Practitioner, and prescribing Physician Assistant under this Open Enrollment Provide Proof of DEA Special Identification Number for each prescribing Physician, prescribing Nurse Practitioner, and prescribing Physician Assistant under this Open Enrollment. Proof of DEA Regular Registration Number for each prescribing Physician, prescribing Nurse Practitioner, and prescribing Physician Assistant under this Open Enrollment Copy of Memorandum of Understanding for each prescribing Physician, prescribing Nurse Practitioner, Physician Assistant under this Open EnrollmentCopy of written agreement with a PharmacyAttach Applicant’s organization chart, detailing oversight structure (governing body) and staff who will manage clinical services (two-page limit). Provide copy of Texas Medicaid and Healthcare Partnership (TMHP) that lists enrollment date, effective date, and Texas Provider Identifier (TPI) number. Provide organization’s Medicaid provider (NPI) number. Attach Certificate of Insurance. ................
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