Department of Human Services
Intensive Behavioral Health Services (IBHS) Attestation forM(To be completed by providers approved to provide Behavioral Health Rehabilitation Services (BHRS) who provide IBHS prior to obtaining an IBHS license)Providers that are seeking payment for providing IBHS prior to obtaining an IBHS license must attest to the following: Choose at least one:___ FORMCHECKBOX ____I attest that [name of provider] FORMTEXT ????? provides individual services or group service and has a clinical director and an administrative director who meet the qualification requirements in 55 Pa. Code § 5240.12(a) and(b) ___ FORMCHECKBOX ____I attest that [name of provider] FORMTEXT ????? provides applied behavioral analysis (ABA) services and has a clinical director and an administrative director who meet the qualification requirements in 55 Pa. Code § 5240.81(a) and (b).Choose at least one:__ FORMCHECKBOX _____I attest that the staff who are providing individual services for which [name of provider] FORMTEXT ????? will be requesting payment through the Medical Assistance (MA) program meet the qualification, training, and supervision requirements for providing individual services in 55 Pa. Code §§ 5240.71, 5240.72, and 5240.73. __ FORMCHECKBOX ____I attest that the staff who are providing ABA services for which [name of provider] FORMTEXT ????? will be requesting payment through the MA program meet the qualification, training, and supervision requirements for providing ABA services in 55 Pa. Code §§ 5240.81, 5240.82, and 5240.83.__ FORMCHECKBOX _____I attest that the staff who are providing group services for which [name of provider] FORMTEXT ????? will be requesting payment through the MA program meet the qualification, training, and supervision requirements for providing group services in 55 Pa. Code §§ 5240.91, 5240.92, and 5240.93. FORMTEXT ?????Name of Provider FORMTEXT ?????Signature of Administrative Director FORMTEXT ?????Date ................
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