Personal Roster



PersonNEl RosterMichigan Department of Health and Human ServicesMaternal Infant Health ProgramAgency NameNPICurrent DateCurrent number of open cases FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Street AddressCityZip CodePhoneFax FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Specialty population served by your MIHP (check all that apply) FORMCHECKBOX Arabic speakers FORMCHECKBOX Refugees: Specify county of origin FORMTEXT ????? FORMCHECKBOX Person who are blind or visually impaired FORMCHECKBOX Spanish speakers FORMCHECKBOX Migrants FORMCHECKBOX Native Americans/ American Indians FORMCHECKBOX Persons who are deaf or hard of hearing FORMCHECKBOX Adolescents FORMCHECKBOX VeteransEnter staff who may have access to any of the following: PHI, MIHP Database, MCIR, and/or MiDR. Refer to the current MSA Medicaid Manual Section 2.1 of the MIHP staffing requirements.MIHP Staff Name(For staff waivered into MIHP, Place an *Asterisk and Date of Waiver)Program Coordinator(Place an X)Professional Title (IMHS, RN, RD, SW, IBCLC)Date HiredExit DateProfessional License Expiration DateAuthorized MIHP Database Users(Place an X)Authorized MCIR User(Place an X)Authorized MiDR User (Place an X)Average # Hours Worked per WeekMeets Minimum Experience Required According to Medicaid Policy (Enter Yes or No) FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Record below any Removed Staff since your last submitted Personnel Roster FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.PERSONNEL ROSTER INSTRUCTIONSAll of the fields must be completed or your agency’s Personnel Roster or it will not be accepted.Personnel Rosters must be submitted to mihp@ and must be submitted in Word format only. We do not accept Personnel Rosters that are faxed, google docs, or pdfs. Do not change the formatting, font, or font size, or remove text on the Personnel Portion of Personnel RosterClick inside the text boxes to enter information and click on the checkboxes. The entire top portion of the Personnel Roster must be completed, if it is not completed or correct, it will not be accepted.In the fields such as AGENCY NAME, NPI, CURRENT DATE, STREET ADDRESS, CURRENT # OF OPEN CASES, CITY, ZIP CODE, PHONE and, FAX, type inside the text boxes The CURRENT DATE – MUST be the date that you submit your agency’s Personnel Roster to the mihp@ mailbox.SPECIALTY POPULATION SERVED BY YOUR MIHP – check the specialty population that your agency serves only if MIHP Provider Specialty Attestation Form has been submitted and it has been approved by an MIHP Consultant.REFUGEES: Please specify country of origin(s) – click inside the text box and enter the country or countries of origin.Middle Portion of Personnel Roster Enter information for staff who may have access to any of the following areas: PHI, MIHP database, MCIR, and/or MiDR. If you have a new staff member that will need access to the MIHP application, MCIR, and/or MiDR, have them register in MiLogin first and then place an X in the Authorized MIHP Database Users column, Authorized MCIR USER column, and Authorized MiDR User. If the staff member has requested access to the MIHP application, MCIR, and MiDR send us their name, username, and email address in the body of the email.MIHP STAFF NAME – enter staff names of all staff members who may have access to any of the following areas: PHI, MIHP database, MCIR, and MiDR.COORDINATOR – Place an X if the staff member if he/she is the MIHP Coordinator column.PROFESSIONAL TITLE – enter if IMHS, RN, RD, SW, etc.DATE HIRED – enter the date hired for all staff. Enter the date as mmddyy. EXIT DATE – enter the date the staff member left the agency. Enter the date as mmddyy.LICENSE EXPIRATION DATE – enter the license expiration date for IMHS, RNs, RDs, SWs, etc. enter the date as mmddyy. AUTHORIZED MIHP DATABASE USERS – place an X if the staff member has access to the MIHP application. Do not place an X if the staff member has not registered in MILogin and has not requested access to the MIHP application. AUTHORIZED MCIR USER – place an X in the column if the staff member has access to the MCIR, or has requested access to MCIR. Do not place an X if they have not requested access to MCIR. AUTHORIZED MiDR USER – place an X if the staff member has access to MiDR. AVERAGE #HOURS WORKED PER WEEK – enter the Average Hours per Week for the staff member. MEETS MINIMUM EXPERIENCE REQUIRED ACCORDING TO MEDICAID POLICY enter Yes or No.Bottom Portion of Personnel RosterRecord below any REMOVED STAFF since your last submitted Personnel Roster:Staff member(s) that have left the agency since the last Personnel Roster was submitted should be listed in the lower portion of Personnel Roster. Their usernames will be inactivated in the MIHP application, MCIR, and MiDR. ................
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