PEN Application and Contract, with instructions - Texas



Applicant and Contract Information DFPS uses the PEN Application and Contract (2280PEN) to create a contract between DFPS and a Contractor for the performance of services that were solicited using the Provider Enrollment (PEN) procurement method. The PEN Application and Contract, Form 2280PEN is included as an attachment to the PEN solicitation. Under §5 of the 2280PEN, DFPS must indicate where the services will be provided. The Contractor will be required to provide services in the geographical area specified in the solicitation, most frequently consistent with a DFPS region. Attachment A-3APPLICATION AND CONTRACTEvaluation & Treatment HHS0000071Identification InformationLegal Name of Applicant FORMTEXT ?????Doing Business As (DBA) NameIf different from Legal Name FORMTEXT ?????Attach a copy of Assumed Name CertificateVendor ID Number FORMTEXT ?????Federal ID Number – If different from Vendor ID FORMTEXT ?????Type of Applicant – Check “√” appropriate box(es) and attach documentation as indicated FORMCHECKBOX Individual/Sole Proprietor FORMCHECKBOX Limited Liability Company (LLC) Attach a copy of the Articles of Formation FORMCHECKBOX CorporationType of Corporation: FORMCHECKBOX For Profit FORMCHECKBOX Non-ProfitState of Incorporation: FORMTEXT ?????Charter Number: FORMTEXT ?????Attach a copy of Certificate of Incorporation FORMCHECKBOX PartnershipType of Partnership: FORMCHECKBOX Limited FORMCHECKBOX GeneralAttach a copy of Partnership Agreement.If applicable, also attach a copy of the Signatory AssignmentContact InformationOffice Address (Street-Suite #) FORMTEXT ?????Office Address (City, State, Zip) FORMTEXT ?????Mailing Address (P.O. Box)If different from Office Address above FORMTEXT ?????Mailing Address (City, State, Zip)If different from Office Address above FORMTEXT ?????Phone- Primary Office FORMTEXT ?????Fax- Primary Office FORMTEXT ?????E-Mail- Primary Office FORMTEXT ?????Name-Primary Contact Person FORMTEXT ?????Title-Primary Contact Person FORMTEXT ?????Phone-Primary Contact Person FORMTEXT ?????Alternate Phone-Primary Contract Person FORMTEXT ?????E-Mail- Primary Contract Person FORMTEXT ?????Name- Person Authorized to Sign Contract FORMTEXT ?????Title- Person Authorized to Sign Contract FORMTEXT ?????Phone- Person Authorized to Sign Contract FORMTEXT ?????Alternate Phone- Person Authorized to Sign Contract FORMTEXT ?????E-Mail- Person Authorized to Sign Contract FORMTEXT ?????Name-Person Responsible for Billing FORMTEXT ?????Title- Person Responsible for Billing FORMTEXT ?????Phone- Person Responsible for Billing FORMTEXT ?????Alternate Phone- Person Responsible for Billing FORMTEXT ?????E-Mail- Person Responsible for Billing FORMTEXT ?????DFPS will send contract-related communications to the primary contact listed above. The Contractor must maintain and monitor at least one active e-mail address for the receipt of contract-related communications from DFPS. Services to Be ProvidedContractor may provide Psychological Evaluation and Testing and/or Psychosocial Assessment and Treatment Services specified in Provider Enrollment HHS0000071. Contractor must provide all Support Services specified in HHS0000071 upon DFPS request.Evaluation and Treatment ServicesServiceService TypeApplying ForEvaluation ServicesTreatment ServicesPsychological Evaluation and Testing FORMCHECKBOX Yes FORMCHECKBOX NoPsychosocial Assessment, Individual, Group and Family Counseling FORMCHECKBOX Yes FORMCHECKBOX NoSupport ServicesCourt Related ServicesDiagnostic ConsultationTranslator & InterpreterAs requested by DFPSBattering Intervention and Prevention Program (BIPP) ServicesServiceService TypeApplying ForEvaluation andIntervention ServicesDomestic Violence Assessment and BIPP Group Intervention (Providers must be TDCJ-CJAD accredited BIPP program providers who are either an LMSW, LCSW, LPC, LMFT or a TDCJ-CJAD funded BIPP Provider) FORMCHECKBOX Yes FORMCHECKBOX NoSupport ServicesCourt Related ServicesDiagnostic ConsultationTranslator & InterpreterAs requested by DFPSService Delivery LocationsYou must determine which counties will be served and mark them in Attachment A-4 Service Delivery Areas. Contractor must provide services within each county selected.Will you, your staff, or subcontractors be delivering services from established office sites other than the location listed in Section C of this application? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, services from these satellite locations are to be billed as In-Office. Designate any satellite office on Attachment A-4 Service Delivery Areas.Indicate locations in which the Contractor is willing to provide services. FORMCHECKBOX In-Office FORMCHECKBOX Out-of-Office FORMCHECKBOX Home-Based (client's home) (not allowable for BIPP)Will you, your staff, or subcontractors be delivering services in any of the CPS Designated Underserved Counties identified on Attachment A-4 Service Delivery Areas? FORMCHECKBOX Yes FORMCHECKBOX NoWill you, your staff, or other subcontractors be delivering telehealth services in addition to at least one of the locations listed in Sections a - d of this application? Note: If you elect to provide telehealth services, you must also provide either In-Office, Out-of-Office or Home-based services in the same region(s) and counties in which you are electing to provide telehealth services. FORMCHECKBOX Yes FORMCHECKBOX NoNOTE: If yes, telehealth services must be billed as In-Office.Contractor BackgroundDoes the Contractor have contracts with DFPS or other State Agencies? FORMCHECKBOX Yes FORMCHECKBOX NoIf yes, is the Contractor's organization currently under any corrective action plan for any of the contracts with DFPS or State Agencies? FORMCHECKBOX Yes FORMCHECKBOX NoHave any contracts been terminated for cause in the last five (5) years? FORMCHECKBOX Yes (Provide copy of termination notice) FORMCHECKBOX NoInsurance7.1Review the minimum insurance requirements in PEN §2.16. Applicants must meet all requirements as outlined. Indicate in the table below, if requirement is met:Commercial General Liability FORMCHECKBOX Yes FORMCHECKBOX NoApplicant does not have required Commercial General Liability insurance, but will obtain within the timeframe defined in the PEN: FORMCHECKBOX Yes FORMCHECKBOX NoProfessional Liability Insurance FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A*Applicant does not carry Professional Liability Insurance for its employees or subcontractors, but will obtain within the timeframe defined in the PEN: FORMCHECKBOX Yes FORMCHECKBOX NoCommercial Crime FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/A*Applicant does not have required commercial crime insurance, but will obtain within the timeframe defined in the PEN: FORMCHECKBOX Yes FORMCHECKBOX NoAttach a copy of the Form 4736, Certificate of Insurance (COI) or equivalent (ACORD Certificate of Insurance, or a copy of the policy) for each policy currently in force and referenced in the table above. Form 4736 has been approved by the Texas Department of Insurance and is the preferred form of insurance verification.*Business entities with no employees and hospitals are exempt from crime policy insurance requirement.For Employees and SubcontractorsApplicant’s organization requires individual professional employees and subcontractors to secure their own Professional Liability Insurance: FORMCHECKBOX Yes FORMCHECKBOX No FORMCHECKBOX N/AIncorporation by ReferenceThe following documents are incorporated into the Contract for all purposes:DFPS Vendor Uniform Terms & Conditions, Form 5645VDFPS Vendor Special Conditions, Form 5622VDFPS Vendor Special Conditions, Form 5622VProvider Enrollment HHS0000071, including all addenda and attachmentsAttachment A-3 and A-4, as completed by the Contractor, including all addenda and attachmentsEach Service Authorization Form 2054, prepared by DFPSOrder of PrecedenceThe Contractor will provide the services and deliverables described and required by all the documents listed in this Section. In the event of conflicts or inconsistencies between documents, such conflicts or inconsistencies will be resolved by reference to the documents in the following order of precedence:This PEN Application and Contract, 2280PEN, and any amendments thereto;9.1.2. DFPS Vendor Uniform Terms & Conditions, Form 5645V9.1.3. DFPS Special Conditions, Form 5622V9.1.4. Provider Enrollment HHS0000071 and any amendments thereto; 9.1.5. Each Service Authorization Form 2054 prepared by DFPS; and 9.1.6. Attachment A-3 and A-4, as completed by the Contractor, including all addenda and attachments, and any amendments thereto.Certification and SignatureI certify that the information provided in this application is, to the best of my knowledge, complete and accurate; that the named legal entity has authorized me, as its representative, to submit this application; and that the legal entity complies with all terms of this Provider Enrollment.By signing this PEN Application and Contract, applicant certifies that if a Texas address is shown as the address of the applicant, applicant qualifies as a Texas Resident Bidder as defined in Texas Administrative Code, Title 34, Part 1, Chapter 20.DFPS will post all official communication regarding this PEN on the Electronic State Business Daily (ESBD). DFPS reserves the right to revise the PEN at any time. Contractors must comply with any changes, amendments, or clarifications posted to ESBD. It is the responsibility of the Contractor to periodically check the ESBD for updates to the procurement. The Contractor’s failure to periodically check the ESBD will not release the Contractor from “addenda or additional information” resulting in additional costs to meet the requirements of the PEN.The undersigned representative agrees to all the terms and conditions specified in the Contract and by signing below agrees to execute the terms and conditions of the Contract upon receipt of a 2054 from the Department. Signature of Authorized Representative FORMTEXT ?????Date FORMTEXT ?????Name of Authorized Representative (Printed) FORMTEXT ?????Title of Authorized Representative (Printed) FORMTEXT ?????DFPS Approval Signature:Signature of Authorized DFPS Representative FORMTEXT ?????Date FORMTEXT ?????Name of Authorized DFPS Representative (Printed) FORMTEXT ?????Title of Authorized DFPS Representative (Printed) FORMTEXT ?????Contract Information – For DFPS Use ONLYDFPS will complete the information below once Application is screened, reviewed, and accepted for contract.NoticesAny notice required or permitted under this contract by the Contractor to DFPS must be in writing and submitted to the DFPS address below:DFPS Office Address (Street;-Suite #; or P.O. Box) FORMTEXT ?????Contract TermContract Number (DFPS staff will complete) FORMTEXT ?????The initial contract period will begin on the effective date stated below, with the total contract term not to exceed sixty (60) months.Effective Date of Contract FORMTEXT ?????End Date of ContractAugust 31, 2021Attachment A-4 Service Delivery AreaService Delivery AreaCounties To Be Served – Region 1Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Armstrong***? Hockley***? Bailey***? Hutchinson***? Briscoe***? King***? Carson***? Lamb***? Castro***? Lipscomb***? Childress***? Lubbock? Cochran***? Lynn***? Collingsworth***? Moore***? Crosby***? Motley***? Dallam***? Ochiltree***? Deaf Smith***? Oldham***? Dickens***? Parmer***? Donley***? Potter? Floyd***? Randall? Garza***? Roberts***? Gray***? Sherman***? Hale***? Swisher***? Hall***? Terry***? Hansford***? Wheeler***? Hartley***? Yoakum***? Hemphill***Service Delivery AreaCounties To Be Served – Region 2Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Archer***? Kent***? Baylor*** ? Knox***? Brown***? Mitchell***? Callahan*** ? Montague***? Clay***? Nolan***? Coleman***? Runnels***? Comanche***? Scurry***? Cottle***? Shackelford***? Eastland***? Stephens***? Fisher***? Stonewall***? Foard***? Taylor***? Hardeman***? Throckmorton***? Haskell***? Wichita***? Jack***? Wilbarger***? Jones***? Young***Service Delivery AreaCounties To Be Served – Region 3Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Collin? Johnson***? Cooke***? Kaufman***? Dallas? Navarro***? Denton? Palo Pinto***? Ellis***? Parker***? Erath***? Rockwall***? Fannin***? Somervell? Grayson***? Tarrant? Hood***? Wise***? Hunt***Service Delivery AreaCounties To Be Served – Region 4Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Anderson? Marion? Bowie? Morris***? Camp***? Panola***? Cass***? Rains***? Cherokee? Red River***? Delta? Rusk? Franklin***? Smith? Gregg? Titus? Harrison? Upshur? Henderson? Van Zandt? Hopkins? Wood***? LamarService Delivery AreaCounties To Be Served – Region 5Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Angelina? Polk***? Hardin? Sabine***? Houston***? San Augustine***? Jasper***? San Jacinto***? Jefferson? Shelby***? Nacogdoches? Trinity***? Newton***? Tyler***? OrangeService Delivery AreaCounties To Be Served – Region 6 ClosedChoose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyAll Regional Counties ClosedAustin***Liberty***Brazoria***Matagorda***Chambers***MontgomeryColorado***Walker***Fort BendWaller***Galveston***WhartonHarrisService Delivery AreaCounties To Be Served – Region 7Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Bastrop***? Hill***? Bell? Lampasas***? Blanco***? Lee***? Bosque***? Leon***? Brazos***? Limestone***? Burleson***? Llano***? Burnet***? Madison***? Caldwell? McLennan? Coryell***? Milam***? Falls***? Mills? Fayette***? Robertson***? Freestone***? San Saba***? Grimes***? Travis? Hamilton***? Washington***? Hays? WilliamsonService Delivery AreaCounties To Be Served – Region 8Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Atascosa? Karnes? Bandera? Kendall? Bexar? Kerr? Calhoun***? Kinney? Comal? La Salle? De Witt***? Lavaca***? Dimmit? Maverick***? Edwards? Medina***? Frio***? Real? Gillespie? Uvalde***? Goliad? Val Verde***? Gonzales***? Victoria***? Guadalupe? Wilson***? Jackson? Zavala***Service Delivery AreaCounties To Be Served – Region 9Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Andrews***? Mason***? Borden***? McCulloch***? Coke***? Menard***? Concho***? Midland? Crane***? Pecos***? Crockett***? Reagan***? Dawson***? Reeves***? Ector? Schleicher***? Gaines***? Sterling***? Glasscock***? Sutton***? Howard***? Terrell***? Irion***? Tom Green? Kimble***? Upton***? Loving***? Ward? Martin***? Winkler***Service Delivery AreaCounties To Be Served – Region 10Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Brewster***? Hudspeth***? Culberson***? Jeff Davis***? El Paso***? Presidio***Service Delivery AreaCounties To Be Served – Region 11Choose the counties within the Region where services will be provided. Check (“√”) the box in front of the county name. Choose a single county or any combination of counties.***CPS Designated Underserved CountyRegional Counties? Aransas***? Live Oak***? Bee***? McMullen***? Brook***s? Nueces? Cameron? Refugio***? Duval***? San Patricio***? Hidalgo? Starr***? Jim Hogg***? Webb***? Jim Wells***? Willacy***? Kenedy? Zapata***? Kleberg***Satellite Offices and Additional Office Information:Please provide a schedule in the table(s) below indicating days and times routinely available to provide services at each service location. These represent only routine days and times. Applicant will be expected to adjust schedule to accommodate the needs of clients and DFPS. Refer to PEN Section 2.5 for additional information. Use additional copies of this section, as necessary, to provide complete information.Name of Applicant/Contractor FORMTEXT ?????1.Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????HOURSDAYFromToFromToExample7 AMNoon2 PM7 PM FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????2.Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????HOURSDAYFromToFromTo FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????3.Service Delivery Address FORMTEXT ?????City, State, Zip FORMTEXT ?????Phone FORMTEXT ?????Fax FORMTEXT ?????Contact Person FORMTEXT ?????E-mail FORMTEXT ?????HOURSDAYFromToFromTo FORMCHECKBOX Monday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Tuesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Wednesday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Thursday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Friday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Saturday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMCHECKBOX Sunday FORMTEXT ????? FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????Attachment A-5 Required FormsAppendix A – Application InstructionsApplicant must submit a completed Application and Required Forms, as applicable, in the order listed below for File Folder 1 and File Folder 2.Access the forms by the link or icon provided below by holding down the "Ctrl" key while clicking on the link. Save forms in an electronic file.For the Application and the forms that require signature, print, sign and scan in an electronic format. Scanned documents must be clear and legible.Attach File Folders 1 and 2 to email and submit the completed Application to the Point of Contact listed in the Open Enrollment Section 1.2.Appendix B – Required FormsFile Folder 1: ApplicationElectronic File NameDescriptionRequired or If ApplicableApplicationApplication for EnrollmentRequiredLicensure and CredentialsClinical License RequiredExperience Evaluation & Treatment Experience Summary (Form K-5627 Experience and Summary) Required Reference LettersTwo (2) reference letters for direct service providers RequiredTF-CBT WebTF-CBT Web Certificate of CompletionRequiredInsuranceInsurance Documentation RequiredDBAAssumed Name Certificate AttachmentIf applicableIncorporationCertificate of Incorporation AttachmentIf applicableLLCLLC Articles of Formation AttachmentIf applicablePartnership Partnership Agreement AttachmentIf applicablePartnersNames and addresses and for each partnerIf applicableHUB HUB Certification FormIf applicableFile Folder 2: Required FormsThe following forms are located on the DFPS public website, Doing Business with DFPS, Contracting Forms: File NameForm Number and NamePurpose74-17674-176, Vendor Direct Deposit FormDirect Deposit Authorization9007FFS9007FFS, Internal Control Structure Questionnaire Contractor's disclosure of internal controls. Instructions included.9105RAQ9105RAQ, Risk Analysis QuestionnaireQuestionnaire for provider to assist staff with the completion of the Risk Assessment Instrument (RAI).AP-152AP-152, Application for Texas Identification Number [If you already have a Vendor ID set up for another DFPS contract, print form, note “Already Set Up” at top of page, and provide number]Application for identification numberThe following form is located on the DFPS public website, Doing Business with DFPS, Contracting Forms, Regional CPS Contracting Forms, General Documents: File NameForm Number and NamePurposePCS-102ETPCS-102ET, Contracting Entity and List of Staff, Subcontractors and VolunteersContractors must list the contracting entity, all service providers, and requested provider information on this form and submit it electronically to DFPS.2970cDisclosure and Consent to Release of Information Regarding Criminal or Abuse/Neglect History For Applicants, Employees or Volunteers of DFPS Contractors and SubcontractorsRelease of information regarding criminal history or DFPS abuse and neglect history.2971cRequest for Background Check for Purchased Client Services Application for requesting criminal history and DFPS abuse or neglect history.4736Certificate of Insurance Contractor submits this form to contract manager to show proof of insurance. The Certificate of Insurance has been approved by the Texas Department of Insurance; it is the only proof of insurance accepted by DFPS, unless the contractor is self-insured.BIPP Application ChecklistSTEP 1: Read the Evaluation & Treatment Open Enrollment for details of the terms and conditions of this contract. Focus on the sections that apply to BIPP Applicants. 2: Organization of Electronic Submission of ApplicationApplicant must organize its scanned and signed Application packet in the following order and format. Each flash drive or compact disc submission of the Application packet must include the following three (3) file folders with the respective listed documents included, and the documents must be in the following order, and numbered and labeled accordingly. Refer to Section 5, Information and Submission Instructions in the Open Enrollment and Section 8, Attachments and Forms (p.94).Items to include in Application PacketYesNoFile Folder 1: ApplicationExhibit 1 - Application and Contract (Form 2280PEN)Exhibit 2 - Attachment A-4 Service Delivery AreasFile Folder 2: Supporting DocumentationExhibit 1 - Verification of Business Entity (Copy of: Certificate of Incorporation, Articles of Formation, Partnership Agreement, or Assumed Name Certificate)Exhibit 2 - BIPP Providers will have a 2-hour Child Welfare Trauma Informed Training Certificate from the completion of webinar 3 - 7 do not apply to BIPP ApplicantsExhibit 8 - Copy of Professional Licenses of direct providers listed on PCS-102ET (2.15.2) if applicable 9 - Verification of Required Insurance coverage including A.M. Best rating (subsection 2.16) File Folder 3: Required Forms Applicants may also access the list of Required Forms at the following alternative link: 1 – Form 2970c Disclosure and Consent to Release of Information --background checkExhibit 2 – Form 2971c Request for Criminal History & DFPS History Check--background checkExhibit 3 – Form 4108x Vendor Direct Deposit --allows DFPS to pay your bank accountExhibit 4 – Form 4109x Application of Texas Identification Number -- needed to identify contracted provider for paymentExhibit 5 – PCS-102ET Contracting Entity - lets us know who is working under your contractExhibit 6 – 9007FFS Internal Control Structure Questionnaire - lets us know how you manage your business financesExhibit 7 – 4736 Certificate of Insurance- or applicant can submit the Certificate of Insurance - ACCORD form in place of this form.NOTE: Each individual document requested in File Folders 1, 2, and 3 must be collated; in sequential order; labeled; and submitted as delineated in this subsection. Attachment A-2 –table AFEE SCHEDULE – EVALUATION SERVICESPayment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider.LICENSED PSYCHOLOGIST (LP), PROVISIONAL LICENSED PSYCHOLOGIST (PLP), LICENSED PSYCHOLOGICAL ASSOCIATE (LPA)Psychological Evaluation & TestingCategoryService - Service CodeLocation & Unit RateIn OfficeHome BasedOut of OfficeTelehealthPsychological EvaluationPsychological Testing-86A$113.91$159.25$113.91Psychological Evaluation by Licensed Psychological Associate (LPA)Psychological Testing (LPA)-86A$79.74$111.48$79.74Incomplete Psychological Evaluation1Psychological Testing-86AMaximum 2 hours$113.91$159.25$113.91Incomplete Psychological Evaluation by Licensed Psychological Associate1Psychological Testing (LPA)-86AMaximum 2 hours$79.74$111.48$79.74Court Related ServicesCourt Testimony-86HDeposition-86HMediation-86H$157.57$157.57$157.57Diagnostic ConsultationDiagnostic Consultation - 81H$112.70$157.57$112.70Translator/Interpreter ServicesService Code 98LCost Reimbursement-Requires Contract Manager prior authorization1Note: Incomplete Psychological Evaluations are defined as after conducting a private individualized face-to-face clinical interview, extenuating circumstances impacted the ability to complete the testing.Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Missed Appointments: Refer to Section 2.13.1Travel: Refer to Section 2.13.3ATTACHMENT A-2 - TABLE BFEE SCHEDULE –TREATMENT SERVICESLICENSED PSYCHOLOGIST (LP)Psychological Counseling ServicesCategoryService - Service CodeLocation & Unit RateIn OfficeHome BasedOut of OfficeTelehealthPsychosocialPsychosocial Assessment – 86U$79.74$111.48$111.48$79.74IndividualIndividual Counseling - 86C$95.93$134.11$95.93Home Based Counseling - Individual - 88K $134.11FamilyFamily Counseling - 86F$79.93$111.75$79.93Home Based Counseling - Family - 88K$111.75GroupGroup Counseling - 86E$23.52$32.88$23.52Court Related ServicesCourt Testimony - 86H$91.19Deposition - 86H$91.19Mediation – 86H$91.19Diagnostic ConsultationDiagnostic Consultation - 81H$65.22$91.19$65.22Translator/Interpreter ServicesService Code 98LCost Reimbursement-Requires Contract Manager prior authorizationAdditional reimbursement for services provided in CPS DESIGNATED UNDERSERVED AREAS: Missed Appointments: Refer to Section 2.13.1 Travel to Underserved County: Refer to Section 2.13.3Attachment A-2 –table CFEE SCHEDULE – EVALUATION AND TREATMENT SERVICESPayment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider.LCSW, LMFT, LPC & LSOTP – Psychosocial Assessment & CounselingCategoryService - Service CodeLocation & Unit RateIn OfficeHome BasedOut of OfficeTelehealth Psychosocial Psychosocial Assessment – 86U$67.15$93.88$93.88$67.15IndividualIndividual Counseling – 86C$67.15$93.88$67.15Home Based Counseling-Individual – 88K$93.88FamilyFamily Counseling – 86F $55.95$78.22$55.95Home Based Counseling-Family – 88K$78.22GroupGroup Counseling – 86E$16.46$23.01$16.46Court Related ServicesCourt Testimony – 86HDeposition – 86HMediation – 86H$63.82Diagnostic ConsultationDiagnostic Consultation – 81H$63.82Translator/Interpreter ServicesService Code 98LCost Reimbursement-Requires Contract Manager prior authorizationAdditional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Missed Appointments: Refer to Section 2.13.1 Travel: Refer to Section 2.13.3Attachment A-2 –table DFEE SCHEDULE – EVALUATION AND TREATMENT SERVICESBATTERING INTERVENTION PREVENTION PROGRAM (BIPP)Payment is based on “unit of service." The allowable unit rate is based on information in the Unit Rate column in the table below.The identified BIPP provider types must maintain accreditation through TDCJ-CJAD.LMSW, LCSW, LMFT & LPC or a TDCJ-CJAD funded BIPPCategoryService - Service CodeLocation & Unit RateIn OfficeOut-of-OfficeTelehealthDomestic Violence Assessment Report 1 unit = 1 assessmentDomestic Violence Assessment Report – 86K$75.00$75.00Group1 unit = 1 hour sessions are 2 hours long (2 units)Orientation and Battering Intervention Prevention Program (BIPP) – 86L$16.46(2 units = $32.92)$23.01(2 units = $46.02)$16.46(2 units = $32.92)Court Related ServicesCourt Testimony – 86HDeposition – 86HMediation – 86H$63.82Diagnostic ConsultationDiagnostic Consultation – 81H$63.82Translator/Interpreter ServicesService Code 98LCost Reimbursement-Requires Contract Manager prior authorizationAdditional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Refer to Billing Requirements in Sections 2.9.6.3.1.4.2 and 2.9.7.2.5.10.Out-of-Office rate applies in accordance with Section 2.5 and is payable when travel exceeds 60 miles and travel to underserved areas has not been claimed. Refer to Section 2.13.3 for details. ................
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