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Home My WebLink About20130671.tiffRESOLUTION RE: APPROVE ENROLLMENT APPLICATION FOR PARTICIPATION AS A MEDICAL PROVIDER IN THE COLORADO MEDICAL ASSISTANCE PROGRAM AND AUTHORIZE CHAIR TO SIGN WHEREAS, the Board of County Commissioners of Weld County, Colorado, pursuant to Colorado statute and the Weld County Home Rule Charter, is vested with the authority of administering the affairs of Weld County, Colorado, and WHEREAS, the Board has been presented with an Enrollment Application for participation as a Medicaid Provider for the Colorado Care Transition Program from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services, Area Agency on Aging, to the Colorado Department of Health Care Policy and Financing, with further terms and conditions being as stated in said application, and WHEREAS, after review, the Board deems it advisable to approve said application, a copy of which is attached hereto and incorporated herein by reference. NOW, THEREFORE, BE IT RESOLVED by the Board of County Commissioners of Weld County, Colorado, that the Enrollment Application for participation as a Medicaid Provider for the Colorado Care Transition Program from the County of Weld, State of Colorado, by and through the Board of County Commissioners of Weld County, on behalf of the Weld County Department of Human Services' Area Agency on Aging, to the Colorado Department of Health Care Policy and Financing be, and hereby is, approved. BE IT FURTHER RESOLVED by the Board that the Chair be, and hereby is, authorized to sign said application. 11�fisD 3/u 2013-0671 HR0084 APPLICATION FOR PARTICIPATION AS A MEDICAL PROVIDER IN THE COLORADO MEDICAL ASSISTANCE PROGRAM PAGE 2 The above and foregoing Resolution was, on motion duly made and seconded, adopted by the following vote on the 11th day of March, A.D., 2013. BOARD OF COUNTY COMMISSIONERS WELD COI Y, COLORADO ATTEST: IMF„ Weld County Clerk to the Board BY: Deputy CI APP to the Boa my Attorney can P. Conway Date of signaturee'AR 19 2013 William Gar eia, Chair ouglas'Rademacer, Pro-Tem ike Freeman arbara Kirkmeyer 2013-0671 HR0084 MEMORANDUM DATE: March 7, 2013 TO: William F. Garcia, Chair, Board of County Cgmmissioners FROM: Judy A. Griego, Director, Department of Human Se RE: Colorado Medical Assistance Program, Provider Enrollment Application on behalf of the Weld County Department of Human Services' Area Agency on Aging Enclosed for Board approval is the Colorado Medical Assistance Program, Provider Enrollment Application on behalf of the Department's Area Agency on Aging. The Provider Enrollment Application was reviewed under the Board's Pass -Around Memorandum dated January 11, 2013, and approved for placement on the Board's Agenda. The Colorado Department of Health Care Policy and Financing obtained a $22 million dollar grant for five years from Centers for Medicare and Medicaid Services (CMS). The primary purpose of the grant is to help transition individuals out of a nursing home setting back into the community utilizing Home and Community Based Waivers with enhanced services that are funded through the grant for a maximum of 365 days. The role of the Options for Long Term Care will be to provide enhanced case management services to the individuals who will be leaving the nursing home. In order for our Options program to receive the additional dollars, we must become a Medicaid Provider. A Provider Enrollment application must be completed and submitted to Medicaid for approval. Once approved as a provider we will be able to bill for the case management services provided using the Medicaid billing system. The Area Agency on Aging has completed the Colorado Medical Assistance Program, Provider Enrollment Application in order to become a Medicaid provider for the Colorado Care Transition Program. The Application must be submitted to the State's contract, Xerox, for approval. The approval process will take approximately 45 days. Once approved by Xerox, the Single Entry Point will be able to bill for Intensive case management services provided to eligible Medicaid clients. The rate of reimbursement will be $21.10 per 15 minutes. If you have additional questions, please contact me at extension 6510. 2013-0671 THE COLORADO MEDICAL ASSISTANCE PROGRAM Provider Services P.O. Box 1100 Denver, CO 80201-1100 Provider Enrollment Application Instructions & Check List All Providers 1-800-237-0757 Fax: 303-534-0439 The forms listed below are required and must be submitted with the application. ( {_� Completed Electronic Funds Transfer (EFT) Form ✓ The individual provider's SSN must be on the EFT form if an individual provider wants to be paid directly under the individual's SSN. ✓ If an individual provider wants payment made to his/her Tax ID Number, a separate application must be completed and submitted to obtain a Group Colorado Medical Assistance Program Provider Number for the Tax ID Number. ✓ The Legal Name on the EFT form must match exactly the Legal Name on file with the IRS. Completed W-9 Form ✓ The individual provider's SSN must be on the W9 form if an individual provider wants to be paid directly under the individual's SSN. ✓ The Legal Name on the W-9 form must match exactly the Legal Name on file with the IRS. ✓ Do not enter the Legal name on the DBA (Doing Business As) Line. ✓ Individual providers must enter their SSN and not their Tax ID Number on the W-9 Form. Individual providers who have a Tax ID number must first enroll as an Individual Colorado Medical Assistance Program Provider under the SSN, then submit a separate application for a Group Provider number under the Tax ID Number. ❑ Submitted Proof of Lawful Presence Documentation and Signed Affidavit (Page 3 of the Application) 4k ✓ This documentation and affidavit is required for all individual provider applicants who are 18 years of age or older AND who will be paid directly. Please refer to the Department of Revenue's Web site at: colorado.gov/revenue Library *Evidence of Lawful Presence: HBO6S-1023 for further information. Submitted Letter Stating Provider Applicant Received an Ell from the Department of Revenue ✓ This letter is required for all individual provider applicants, who are 18 years of age or older, AND who will be paid directly, AND who will be providing proof of lawful presence via the signed affidavit AND obtaining a waiver from the Department of Revenue. Please refer to the Department of Revenue's Web site at: colorado.g, v reranru' *Librnrn *Evidence oft,awlid Prc'eece: 111306S-1023 for further information. FLicense Attached ✓ Include license or certification. Refer to Appendix A of the application to determine whether a license or certification is required. Ni Submit a copy of the license with the Actual License Begin Date. If the license does not have a Begin Date, obtain a document with the Begin Date from the licensing board. ✓ Submit a copy of the license with the Expiration Date for the license. If the license does not have an Expiration Date, obtain a document with the Expiration Date from the licensing board. yjt Completed Change of Ownership or Change of Tax ID Number Form (Page 1 of the Application) ✓ I This form is required and must be returned with all requested documentation and the completed application. Completed Provider Disclosures Page (Page 13 of the Application) ✓ This page must be completed for all providers. Please refer to the Code of Federal Regulations, Title 42, parts 455.104 and 455.106, located on the Web at 11172: 'XX wss access.gpo.«ovinara clicfr-table-search.hnnl?pagcl. ✓ Entering N/A is not an acceptable response. This section must be completed in its entirety. Please list those who have an ownership interest equal to five percent or more as well as the officers, directors, and partners of the disclosing entity. h S1Completed ✓ Supervising Physician Form (if applicable) This form is required and must be returned with the application for certain provider types listed in Appendix A of the application. Revised: July 2009 Page 1 of 2 THE COLORADO MEDICAL ASSISTANCE PROGRAM Provider Services P.O. Box 1100 Denver. CO 80201-1100 Individual Providers Affiliated with a Grou 1-800-237-0757 Fax: 303-534-0439 Completed Electronic Funds Transfer (EFT) Form ✓ This form is not required if the application is for an individual provider affiliated with a group and the group provider is always the billing provider. Enter the group affiliation provider number on Page 12 of the application. ✓ If an individual provider wants payment made to his/her Tax ID Number, a separate application must be completed and submitted to obtain a Group Colorado Medical Assistance Program Provider number for the Tax ID Number. Enter the Tax ID Number on the EFT Form. ❑ Completed EDI Authorization Form ✓ If an individual provider bills under a group number, the provider must authorize the group's Trading Partner ID to submit transactions electronically on the provider's behalf by completing the EDI Provider Authorization Form. Group Providers /El Completed W-9 Form ✓ The Legal Name on the W-9 form must match exactly the Legal Name on file with the IRS. ✓ Do not enter the Legal name on the DBA (Doing Business As) line. ✓ Enter the Tax ID Number on the correct entity line (e.g., A corporation enters their Tax ID Number on the "Corporation" line). Contact Name ICUcz_, Ccwt( Contact Phone Number t -Tic 3'/, -69so ruici Revised: July 2009 Page 2 of 2 COLORADO MEDICAL ASSISTANCE PROGRAM STANDARD PROVIDER APPLICATION Colorado Medical Assistance Program PO Box 1100 Denver, Colorado 80201-1100 1-800-237-0757 or 1-800-237-0044 colorado.gov/hcpf Table of Contents CHANGE OF OWNERSHIP OR CHANGE OF TAX IDENTIFICATION NUMBER 1 ALL APPLICANTS MUST COMPLETE Change of Ownership Information NAME AND BUSINESS ORGANIZATION INFORMATION 2 ALL APPLICANTS MUST COMPLETE Name and Type of Business Practice and Legal Name VERIFICATION OF LAWFUL PRESENCE IN THE UNITED STATES 3 ALL INDIVIDUAL APPLICANTS WHO WILL RECEIVE DIRECT REIMBURSEMENT MUST COMPLETE Affidavit PROVIDER ADDRESS INFORMATION 4 ALL APPLICANTS MUST COMPLETE Service Location Address & Phone Information Billing Office Address & Phone Information Mailing Address & Phone Information Faxback Eligibility Telephone Number PROVIDER/SUBMITTER ELECTRONIC INFORMATION 5 ALL APPLICANTS SUBMITTING CLAIMS OR RETRIEVING REPORTS ELECTRONICALLY MUST COMPLETE Electronic Transactions Submitter ID or Trading Partner ID Contact Information EDI PROVIDER AUTHORIZATION FORM ALL PROVIDERS AUTHORIZING A BILLING AGENT, CLEARINGHOUSE, OR ANOTHER PROVIDER TO SUBMIT OR RETRIEVE TRANSACTIONS ON THEIR BEHALF MUST COMPLETE AND SIGN 7 PROVIDER TYPE 8 ALL APPLICANTS MUST COMPLETE Provider Type LICENSURE AND SPECIALTY INFORMATION 9 ALL APPLICANTS MUST COMPLETE Licensure Information Practitioner Specialty Information PROVIDER CERTIFICATION AND REGISTRATION INFORMATION 9 ALL APPLICANTS MUST COMPLETE Malpractice Information Pharmacy Registration Information CLIA Registration Information Institutional Bed Information Other Registration Information PROVIDER DISCLOSURES 10 ALL APPLICANTS MUST COMPLETE ADDITIONAL PROVIDER PARTICIPATION INFORMATION ALL APPLICANTS MUST COMPLETE MEDICARE PARTICIPATION INFORMATION 11 Revised: November 20101 AFFILIATION INFORMATION - GROUP AND CLINIC MEMBERS 12 INDIVIDUAL PRACTITIONER APPLICANTS WHO WILL SUBMIT CLAIMS THROUGH A GROUP OR CLINIC MUST COMPLETE SIGNATURE AUTHORIZATIONS - REQUEST FOR ORIGINAL SIGNATURE ALTERNATIVE 13 APPLICANTS WHO WISH TO AUTHORIZE ALTERNATIVE FORMS OF SIGNATURE ON CLAIMS MUST COMPLETE PROVIDER PARTICIPATION AGREEMENT 14 ALL APPLICANTS MUST READ AND SIGN PAYMENT REPORTING AND PUBLICATION EMAIL PREFERENCE 22 ALL APPLICANTS MUST COMPLETE APPENDIX A - REFERENCE INFORMATION FOR SERVICES INDENTIFICATION A-1 PROVIDER TYPES AND LICENSURE REQUIREMENTS THE FOLLOWING DOCUMENTS ARE INCLUDED IN THE PACKET AND ARE NOT NUMBERED W-9 - REQUEST FOR TAXPAYER IDENTIFICATION NUMBER (TIN) VERIFICATION FORM AND INSTRUCTION SHEET COMPLETION IS REQUIRED AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS FORM AND INSTRUCTION SHEET APPLICANTS ARE REQUIRED TO COMPLETE THIS FORM TO RECEIVE MEDICAL ASSISTANCE PROGRAM PAYMENTS THROUGH ELECTRONIC FUNDS TRANSFER Revised: November 20101 ii Change of Ownership or Change of Tax ID Number All applicants must complete Providers are reminded that a change of ownership or a change of tax ID number terminates the Medical Assistance Program Provider participation agreement. New owners and providers with new tax ID numbers must re -apply and complete a new Medical Assistance Program Provider Participation Agreement in order to participate in the Colorado Medical Assistance Program. Change of Ownership Information Is this application the result of a change of ownership or a change of tax ID number? Did you purchase this business or practice from an enrolled Colorado Medical Assistance Program provider? If no, sign and submit this form with your application. If yes, you must complete the following information. No X Yes ❑ No Or Yes ❑ Enter the name and Colorado Medical Assistance Program provider number of the closing (selling) provider. If you have a new tax ID number and still own your company, enter the name and Medical Assistance Program provider number associated with your old tax ID number. Name: Provider number Effective date of change of ownership or change of tax ID number: If this is a Change of Ownership, we must receive a statement from the closing (selling) provider including: ✓ The name of the opening (purchasing) provider, So The effective date of the change of ownership, and ➢ A forwarding address. If this information is not provided, your application will not be processed. You may not submit claims for dates of service before your application is activated. In addition, while your application is in process, you may not submit claims using: The closing provider's Colorado Medical Assistance Program provider number or • The Colorado Medical Assistance Program provider number associated with your old tax ID number. Signature and date All providers must sign and date Provider Signature MAR 1 1 2013 Date Revised: November 20101 1 Name and Business Organization Information All applicants must complete Providers must enroll as either an Individual or a Business Name and Type of Business Practice Individuals (Applying under Social Security #) Individual practitioners must enroll using the name shown on their social security card. If payments for services are to be made to a group practice, partnership, or corporation, then the group, partnership, or corporation must enroll and obtain a Medical Assistance Program provider number to be used for submitting claims as the billing provider. All individual practitioners who render services must be enrolled. 2 Individual's Last Name First Name M.I. Title/Degree Business ventures (sole proprietors, groups, partnerships, and corporations) (Applying under a Tax ID) (1r;l,r-di n -I 1,72/*/ egal business name (exactly as registered with the Internal Revenue Service) Doing Business As (DBA) name (if applicable) Mark the applicable type of business: O Partnership O Limited Liability 0 Sole Proprietor 0 Other Partner O Trust X Government Agency 0 Corporation Institutions (Hospitals) Legal business name (exactly as registered with the Internal Revenue Service) Doing Business As (DBA) name (if applicable) Mark the applicable type of business: O Partnership 0 Limited Liability 0 Sole Proprietor 0 Other Partner O Trust 0 Government Agency 0 Corporation Indicate the type of control of the facility (please check one) O State 0 Federal 0 Indian Health Center 0 Other Please check if you have seen Colorado Medical Assistance clients within the past 120 days ■ This space for fiscal agent use Revised: November 20101 2 Verification of Lawful Presence in the United States All applicants who will receive direct reimbursement must complete 3 Verification of Lawful Presence in the United States Individuals Please refer to the Department of Revenue's Web site at http://www.colorado.gov/revenue *Library *Evidence of Lawful Presence: HB06S- 1023 for further information. Each individual provider applicant who is 18 years of age or older who will receive direct reimbursement must attach a photocopy of one of the following documentation types AND sign the following affidavit Pursuant to C.R.S. § 24-76.5-103, on or after August 1, 2006, each agency or political subdivision of the State shall verify the lawful presence in the United States of each natural person eighteen years of age or older who applies for state or local public benefits or for federal public benefits by requiring the applicant to produce one of the following: 1) A valid Colorado driver's license or a Colorado identification card; or 2) A United States military card or a military dependent's identification card; or 3) A United States Coast Guard Merchant Mariner card; or 4) A Native American Tribal Document AND Execute the affidavit below. AFFIDAVIT for the Colorado Department of Health Care Policy and Financing as Proof of Lawful Presence in the United States , swear or affirm under penalty of perjury under the laws of the State of Colorado that (check one): I am a United States citizen. I am not a United States citizen but I am a Permanent Resident of the United States. _ I am not a United States citizen but I am lawfully present in the United States pursuant to Federal law _ I am a foreign national not physically present in the United States. I understand that this sworn statement is required by law because I have applied for a public benefit. I understand that state law requires me to provide proof that I am lawfully present in the United States prior to receipt of this public benefit. I further acknowledge that making a false, fictitious, or fraudulent statement or representation in this sworn affidavit is punishable under the criminal laws of Colorado as perjury in the second degree under Colorado Revised Statute 18-8-503 and it shall constitute a separate criminal offense each time a public benefit is fraudulently received. Signature Date Name (please print) Social Security Number Revised: November 20101 3 Provider Address Information Service Location Address & Phone Information All applicants must complete All applicants must complete. Provide the street address of the location where services will be rendered. 3/:S Aloe —Hi // 't 44,r - reel 7 City Street address (must be street address) (4'70 ) 3ti6—G,(13&rCe/Dl Voice Telephone number Lae k J County do c'.e)CP 3 / State Zip ( Qr70 ) 3'v4 -l.,Q / Fax Telephone number Billing Office Address & Phone Information Complete the following information if the billing office address is different from service location address. Payments (if any) made under the assigned provider number will be sent to this address if different from the service location address. I/ 56 L 5frcc:.,t ? O..6OX -i55)) 1806, 2) 6jrrel Play (400 ) 39F- 7?C Voice Telephone number Business e-mail address: Street address, PO Box Weld do County State ( Q7o ) 35i - tio/9 Fax Telephone number 6O[o a 7 Zip Mailing Address & Phone Information Complete the following information if the mailing office address is different from service location and billing addresses. Special mailings (if any) made under the assigned provider number will be sent to this address if different from the service location and billing addresses. Yo 42 Box 18a Y celpy ( Qt`ID City Street address, PO Box County State Zip 3y4 695-D) ela) ( (MD ) 3A/ 4, o,c7l ) Voice Telephone number Business e-mail address: Fax Telephone number All providers must complete the Payment Reporting and Publication Email Preference page (page 22 of this application). leFaxback Eligibility Telephone Number Faxback eligibility allows providers to verify eligibility by telephone and, after hearing the information spoken, receive a fax with the information. If you wish to use this service, your fax telephone number must be recorded on your provider enrollment record. Please identify the telephone number where the faxback eligibility report should be sent. Only a single faxback number can be recorded. Faxback telephone number ( P110 ) - l6 4's / Revised: November 20101 4 9 Provider/Submitter Electronic Information All applicants submitting claims or retrieving reports electronically must complete Colorado Medical Assistance Program rules (8.040.2) require the electronic submission of claims except in certain circumstances. Providers may also retrieve reports electronically. In order to electronically submit claims, or electronically retrieve reports, applicants must complete these sections. Please indicate how you plan to submit your electronic transactions Electronic Transactions ❑ Vendor Software ❑ Billing Agent ❑ Clearinghouse/Switch Vendor Transactions available for transmission X12N 270 (Eligibility Inquiry) X12N 276 (Claim Status Inquiry) X12N 278 (Prior Authorization) State's Provider Web Portal X12N 837P (Professional Claim) X12N 837D (Dental Claim) ® X12N 8371 (Institutional Claim) Electronic Report/ Response Retrieval If you are currently submitting electronic transactions directly to the fiscal agent for the Colorado Medical Assistance Program, please indicate your 5 -digit Submitter ID or 6 -digit Trading Partner ID. ❑❑❑❑❑❑ All software vendors must have their own uniquely assigned Submitter or Trading Partner ID to act on your behalf. Please contact your software vendor to confirm their status. Please enter your software vendor's 5 -digit Submitter ID or 6 -digit Trading Partner ID. Software Product DEEDED Transactions Available for Receiving Reports Colorado Medical Assistance Program providers can receive X12N electronic reports. Please select the reports that you want to receive through the State's Provider Web Portal. Enter only one Trading Partner (TP) ID per report. You may enter a different TP ID for each selected report. X12N 824 (Payer Specific Error Report) will by default be returned to submitting TP ID X12N 271 (Eligibility Response) will by default be returned to submitting TP ID X12N 997 (Acknowledgement of a sent transaction) will by default be returned to submitting TP ID X12N 277 (Claim Status Response) will by default be returned to submitting TP ID If the Receiving TP ID field is left blank, it will by default be returned to submitting provider's TP ID Receiving TP ID Receiving TP ID ❑ ❑ X12N 835 (Claim payment/Claim report X12N 820 (Client Capitation) Accept/Reject Report PCP Roster X12N 834 (Benefit Enrollment and Maintenance) PAR Letters Element Delimiter to be used: Default Delimiter (asterisk) * Provider Claim Report (Previously called the Remittance Advice Report) ❑ Managed Care Transactions ❑ ACC Roster Report Sub -element Delimiter Segment Delimiter to be used: n to be used: Default Delimiter (colon) : Default Delimiter (tilde) The Department will provide you with more information at a later date, including a User ID and Password, under separate cover. Revised: November 20101 5 Provider/Submitter Electronic Information - Continued All applicants submitting claims or retrieving reports electronically must complete 10 Contact Information Contact Individual Name: Primary Contact Information/Trading Partner Administrator f eivkid-, First Name C --Last f+ Name Contact Title: /101? Business Street Address: 3/j N, i/ r s \ .v . 'goy 4 _=-7 I City:F,t?,e,(43.2_nridl� rcelw� State: Cry ZiP PaNcv-4 Telephone: gib -'352- I Ss I 1,(4a Fax: Q no 3 Yc, - 176 9) 3 Business email address: huffD4 rid �d We 143nv. I om Secondary Contact Information/Trading tiPartner Administrator Contact Individual Name: iyt, c Hr t i e- B n i h tt 3 First Name Last Name p5) Contact Title: lee „itaH c e rlG Business Street Address: '3 is- N, tlf' )4N¢ 1?b.60VA- v0(o32 r o'ddie�s� City: CI rc-ei t` State: C o Zip: go& sj Telephone: yip h5? - i S5 I v %53 z Fax: 910 '',u b - 'I L. 8 Business email address: bo i k,'t , aw L id C. /crn Revised: November 20101 6 EDI Provider Authorization Form All providers authorizing a billing agent, clearinghouse, or another provider to submit or retrieve transactions on their behalf must complete and sign EDI Provider Authorization Form This Authorization must be completed and signed by the provider who wishes to authorize a billing agent, clearinghouse or other provider to: • Maintain and control designated reports • Submit and/or retrieve designated transactions The authorized billing agent, clearinghouse, or provider will not be allowed to access information on a provider's behalf without the submission of this explicit authorization. Provider, hereby appoints Provider Name (please print) Billing Agent/Clearinghouse/Provider Name (please print) Billing Agent/Clearinghouse/Provider Trading Partner/Submitter ID to act as an authorized agent for the purpose of submitting health care transactions electronically on Provider's behalf to the Colorado Medical Assistance Program. Provider must check one box below: nProvider authorizes the listed agent to retrieve some or all electronic reports/responses on Provider's behalf. OR Provider does NOT authorize the listed agent to retrieve electronic reports/responses on Provider's behalf. Provider/Provider Representative Name (please print) Provider/Provider Representative Signature Date Provider Number This Authorization may be modified or revoked at any time in writing. It is considered in effect until modified or revoked. This form must be completed by the billing provider not a rendering provider. Revised: November 20101 7 Provider Type All applicants must complete All applicants must complete. From the list below, identify the provider type (refer to the provider type listing in Appendix A) appropriate to this application. You must complete a 11 Provider separate application for each provider type (check only one box). If you do not find the Type appropriate provider type on the list below, you may not be eligible to enroll in the Medical Assistance Program at this time. Please call the Medical Assistance Program Provider Services at 1-800-237-0757 for assistance and further directions. Ambulatory Surgical Center (44) Audiologist (19) Case Manager (11) Chiropractor (18) Clinic Community Mental Health (35) Developmental Evaluation (46) Family Planning (29) Organized Health (16) Dental Dentist (04) Orthodontist (04), Specialty (63) Dental Hygienist (04), Specialty (66) Dental Clinic (47) Developmental Disabilities (HCBS Waiver Services) (36) (Select only 1 box in this area) Children's Habilitative Residential Program (CHRP) Colorado Choice Transitions DD/SLS HCBS-DD - Group Home Services HCBS DD Children's ExtensiveSupport(CES) Day Habilitation Services Individual Residential Services & Support Supported Living Services (SLS) Dialysis Center (33) FQHC Freestanding (32) FQHC Indian Health Services (32) Home Health (10) Hospice (50) Hospital General (01) Mental (02) Laboratory, Independent (12) Medicare Crossover Benefits (18) Mental Health Practitioner Psychologist PhD Level (37) Psychologist MA Level (38) LCSW, LMFT and LPC Nurse Anesthetist, CRNA (40) Nurse Midwife (22) Nurse Practitioner (41) Nursing Facility ICF-MR (21) Hospital Back-up Unit (20) Skilled (20) • ■ ■ ■ • • ❑ • • ■ ❑ ■ • 0 • • ❑ U ❑ • ■ ■ ■ ■ ❑ ■ ■ ■ • ■ ■ ■ ■ Optician/Optical Outlet (08) Optometrist (07) Pharmacy (09) Pharmacy Indian Health Service Mail Order Rural Dispensing Physician Site Physician M.D. (05) D.O. (26) Podiatrist (06) Practitioner Billing Groups Physician (16) Non -Physician Practitioner (25) Prepaid Health Plan HMO (23) Mental Health (31) Psychiatric Residential Treatment Facility (30) Regional Care Coordination Organization (RCCO) (57) Rehabilitation Agency (48) Comprehensive Outpatient Rehabilitation Facility (CORF) Practitioner Residential Child Care Facility (RCCF) (52) Rural Health Center (45) School Health Services (51) Substance Abuse M.D. (05) Clinic (16) D.O. (26) Psychologist, PhD Level (37) Licensed Mental Health Practitioner (38) Family/Pediatric Nurse Pract (41) Supply/DME (14) Transportation Ambulance (13) Non -Emergency Transportation (13) AirAmbulance (13) Therapist Occupational (28) Physical (17) Speech (27) X-ray Facility, Freestanding (49) • • • • • ■ ❑ ■ ■ ■ • ■ ■ ■ ■ ■ ■ ❑ ■ ■ ❑ • • • • ■ ■ 0 ■ ■ ■ ■ ■ ■ Waiver Services (HCBS) (34) (Check all boxes applicable for the Waiver Services listed below.) Adult Day Services Alternative Care Facility Behavioral Programming Behavioral Therapies (Autism) BI Assistive Technology Children's Case Management Colorado Choice Transitions Assistive Technology Caregiver Education Community Transition Services Dental Enhanced Nursing Services Home Delivered Meals Home Modifications Independent Living Skills Training Intensive Case Management Peer Mentorship Transitional Behavioral Health Supports Transitional Specialized Day Rehabilitation Services Transitional Substance Abuse Counseling Vision Community Transition Services Day Treatment Electronic Monitoring Home Modification In -Home Support Services Independent Living Skills Training Mental Health Counseling Non -Medical Transportation Pediatric Hospice Waiver Home Health Hospice Personal Care/Homemaker Therapy & Counseling Personal Care/Homemaker Substance Abuse Counseling Supported Living Program Transitional Living Program ❑ ■ ■ • ■ • ■ ■ • ❑ ❑ ■ ■ ■ K ((�] • • • ■ 0 ■ ■ ■ ■ ■ ■ U ■ ■ ■ ❑ ■ ■ ❑ ❑ Revised: November 20101 S Licensure and Specialty Information All applicants must complete Complete if applicable. Provider types requiring license information are identified in Appendix A. Attach a copy of license(s). Please include copies that contain the original effective date and expiration date. Licensure License Number License Authority/Board Expiration Date IIIIIPractitioner Specialty Information All practitioners please complete. If board certified, please provide the specialty board certification number, effective date, and expiration of certification. If needed, provide additional information on the reverse or attach additional pages. Specialty Certificate Number Effective Date Expiration Date Provider Certification and Registration Information All applicants must complete Malpractice/ General Liability Information Malpractice/General liability insurance is mandatory under current State and Federal laws Malpractice/General Liability Ins• urance Carrier: Pao Ie &.e o lto ( Ii eci 15 Pharmacy Registration Information Pharmacy applicants must complete. Failure to complete this section may affect reimbursement rates. National Council on Prescription Drug Programs (NCPDP) number (7 digit number) (Formerly National Association of Board Pharmacies (NABP) number) Pharmacy classification (check one) ❑ Metro (independent) O State Government ❑ Mail Order ❑ Rural (Independent) 0 340B ❑ Hospital Federal Government ❑ Chain 0 Hospital ❑ Specialty/Infusion 0 Retail CLIA Registration Information Applicants who provide laboratory testing services must complete. Enter your current CLIA registration number(s). If you do not perform CLIA office testing, you may omit this section. Attach a photocopy of your CLIA certificate that indicates the effective date and the expiration date. (Attach additional pages if necessary.) Note that this information is for CLIA certificates that you hold, not for laboratories, etc. that you use. CLIA Number Certification Type Effective Date Expiration Date Revised: November 20101 9 A�RO� CERTIFICATE OF LIABILITY INSURANCE D12/13/ (MM/DD/YYYY) 2 12/13/2012 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER 1-303-773-9999 Arthur J. Gallagher Risk Management Services, Inc. 6399 S. Fiddlers Green Cir Suite 200 Greenwood Village, CO 80111 Karen Graham CONTACT Anita Bruner NAME: PHONE 303-889-2574 FAX 303-889-2575 INC No Exti-IA/C. No): E-MAIL ADDRESS: smite bruner@ajg.com INSURER(S) AFFORDING COVERAGE NAICe INSURER A: Colorado Counties Casualty & Property INSURED Weld County P.O. Box 758 Greeley, CO 80632 INSURER B: ATLANTIC SPECIALTY INS CO 27154 INSURER C' LEXINGTON INS CO 19437 INSURERD: INSURER E: INSURER F : COVERAGES CERTIFICATE NUMBER: 30643350 REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR MAY PERTAIN, THE INSURANCE AFFORDED BY THE POLICIES DESCRIBED HEREIN IS SUBJECT TO ALL THE TERMS, EXCLUSIONS AND CONDITIONS OF SUCH POLICIES. LIMITS SHOWN MAY HAVE BEEN REDUCED BY PAID CLAIMS. INSR LTR TYPE OF INSURANCE ADOL INSR SUER WVD POLICY NUMBER POLICY EFF (MMIDDIYYYY) POLICY EXP (MMIDDIYYYY) LIMITS A GENERALLIABIUTY X COMMERCIAL GENERAL LIABILITY PER PARTICIPATION CERT. 01/01/13 01/01/14 EACH OCCURRENCE $ 250,000 DAMAGE TO REN 'ID PREMISES (Ea occurrence) $ XI CLAIMS -MADE OCCUR MED EXP (Any one person) $ PERSONAL& ADV INJURY $ 250,000 GENERAL AGGREGATE $ GENt AGGREGATE POLICY LIMIT APPLIES PF? PER: LOC PRODUCTS - COMP/OP AGG $250,000 $ A AUTOMOBILELIABILITY X X X ANY AUTO ALL OWNED _ X SCHEDULED AUTOS NON -OWNED AUTOS PER PARTICIPATION CERT. 01/01/13 01/01/14 COMBINEDSINGLE LIMIT SEa acciden0 $ 250,000 BODILY INJURY (Per person) $ BODILY INJURY (Per accident) $ PROPERTY DAMAGE (Per accident) $ $ B X UMBRELLA LAB EXCESS LIAB X OCCUR CLAIMS -MADE 7910003550002 01/01/13 01/01/14 EACH OCCURRENCE $ 10,000,000 AGGREGATE $ 10,000,000 DED IX IRETENT ON$ 250,000 $ WORKERSCOMPENSATION ANDEMPLOYERS'LIABILITY ANY PROPRIETORIPARTNERIEXECUTIVE OFFICER/MEMBER EXCLUDED? (Mandatory in NH) If yes. describe under DESCRIPTION OF OPERATIONS below YIN NIA WC STATU- 0TH- TORY LIMIT$ ER $ E.L. EACH ACCIDENT E.L. DISEASE - EA EMPLOYEE $ E.L. DISEASE - POLICY LIMIT $ C A EXCESS PROPERTY Prop, Mob Eq, Auto PD, XS 020412751 PER PARTICIPATION CERT. 01/01/12 01/01/12 01/01/14 01/01/14 BLANKET BLDG & PP 100,000,000 Member Ded = $500 150,000 DESCRIPTION OF OPERATIONS / LOCATIONS / VEHICLES (Attach ACORD 101, Additional Remarks Schedule if more space is required) Umbrella Liability coverage includes E&0 coverage for alleged violations for privacy rights. RE: Area Agency on Aging contract with the State of Colorado. CERTIFICATE HOLDER CANCELLATION State of Colorado Division of Aging & Adult Services 1575 Sherman, 10th Floor Denver, CO 80203 USA SHOULD ANY OF THE ABOVE DESCRIBED POLICIES BE CANCELLED BEFORE THE EXPIRATION DATE THEREOF, NOTICE WILL BE DELIVERED IN ACCORDANCE WITH THE POLICY PROVISIONS. AUTHORIZED REPRESENTATIVE ACORD 25 (2010/05) gokden 30643350 © 1988-2010 ACORD CORPORATION. All rights reserved. The ACORD name and logo are registered marks of ACORD SUPPLEMENT TO CERTIFICATE OF INSURANCE DATE 12/13/2012 NAME OF INSURED: weld County Additional Description of Operations/Remarks from Page 1: Excess Property: Carrier: Lexington Insurance Company Policy #020412751 Policy Term: 01/01/2013 to 01/01/2014 $100,000 Loss Limit - Excess Property/Real & Personal Property (All Risk) including Equipment Breakdown $5,000,000 Each Occurrence/Annual Aggregate - Flood, Zone A $50,000,000 Each Occurrence/Annual Aggregate - Flood, all other Zones $50,000,000 In the Aggregate as respects all flood loss combined $25,000,000 Each Occurrence/Annual Aggregate - Earthquake No Coverage for Rental Income $150,000 Deductible All Perils / $5,000 Deductible Equipment Breakdown except $10,000 applies to Snake River Was Water Treatment Facility in Dillon, CO Additional Information: tE SUPP (05/04) Provider Certification and Registration Information - Continued All applicants must complete Hospital and Nursing Facility applicants must complete. Institutional Bed Information Hospitals 4 Nursing Facilities r► ACF 4 Number of Inpatient beds Number of Skilled Beds Number of ICF Beds Number of ACF Beds Other Registration Information Applicants with a Drug Enforcement Agency Number, National Provider Identification Number or a Taxonomy Number must complete. Provide the requested information below. DEA Number 4 NPI Number* 4 Taxonomy Number* 4 Number Begin Date End Date *The following provider types are not required to submit an NPI or Taxonomy number: Non -Emergency Transportation, Home & Community Based Services or Waiver providers, Case Management providers, Managed Care Health Plans, & Behavioral Health Organizations. All other provider types need to submit an NPI. Provider Disclosures All applicants must complete Pursuant to federal regulations at 42 CFR §§ 455.104 and 455.106, Providers who are a corporation, limited liability corporation or partnership (disclosing entities) must disclose the information listed under "Legal Name & Business Category". Providers who are sole proprietors must return the form with their names inserted and must indicate (✓) "Sole proprietor". If you are an individual provider, please complete the "Individuals" portion only. Please enter name Eiga on JC= your - I,oc=c-L. 19 Individuals Have you been convicted of a criminal offense?* ❑ Yes f2(No If yes, please explain: (Attach additional sheets if needed) Legal Name Please enter the legal name of your business _.(1/),,,,,,..3, �D F Z./..)6 ----EL) & Business and ✓ the business category:// Category ❑ Sole proprietor ❑ Partnership Please list the name(s) and address(es) of each person subcontractor in which the Provider has direct or indirect ■ ❑ with ownership Corporation IN.Government Limited Liability Corporation an ownership or control interest in the Provider or in any of 5% or more. Please indicate whether any of the persons named in one to four below are related to any of the other persons named in one to four below as a spouse, parent, child or sibling. Corporations, LLC, Non -Profits must list Board of Directors in 1-4 below. Government agencies must list local management structure in 1-4 below. Additional space provided on next page. Person # Name Address City, State, Zip Relationship to Persons Named in 1 - 4 Convicted of a criminal offense?* Circle One 1. IUd1 Cif ;esD 3lSN.II+^+ Avc 6Peel tt Co yD4i1 Dirccirn Yes (Ng) 2. Eva_ -3.24_,..).cll Sts u 04'Atte., 1-rrcet55 Co Bete 31Dip.5,0r-t l4cod Yes No) 3. Sotic},� I�dt,GN '3t S N. lIH G1scdr� Cu °obL31 5upofv.5o� Yes No„ 4. Iroc-( R\,o-1-os.t 3if ki O1CI rccte)ii) 'ices 3' Sk2efvisu,' Yes Noj _;_elated to Medicare, Medical Assistance Program or Title XX services program since the inception of those programs. Revised: November 20101 10 Provider Disclosures - Continued All applicants must complete Please indicate the name of any other disclosing entity in which the persons listed in one through four above also have an ownership or control interest. This requirement applies to the extent that the Provider can obtain this information by requesting it in writing from the person. This space for fiscal agent use FA Initial Review Date: Additional Provider Participation Information All applicants must complete 20 Medicare Participation Information Complete the information requested below about Medicare participation. To receive Medical Assistance Program payments for services provided to individuals who have Medicare and Medical Assistance Program benefits, providers must accept assignment of their Medicare claims. Automatic crossover is an exchange of claim information between Medicare and the Medical Assistance Program. When automatic crossover occurs, providers do not have to submit a crossover claim to the Medical Assistance Program. The Colorado Medical Assistance Program obtains crossover claim information from Colorado Medicare carriers and intermediaries. For automatic crossover to occur, providers must identify their NPI numbers. If you wish to have assigned Medicare claims cross automatically to the Medical Assistance Program, please list your NPI number(s) in section 18 on page 10. Individuals who are part of a group or clinic should only list their individual numbers, not the group's base number. Dr This applicant does not participate in Medicare D This applicant does participate in Medicare ❑ Medicare PartA O Medicare Part B Please attach a copy of the Medicare Certification letter. Automatic crossovers should occur when the participant has registered their NPI with Medicare Part A and/or Part B and in the Medical Assistance Program claims processing system (MMIS). Medicare numbers are no longer valid for automatic crossover from Medicare Part A and Part B to the Medical Assistance Program. Revised: November 20101 11 Affiliation Information - Group and Clinic Members Individual practitioner applicants who will submit claims through a group or clinic must complete. 1. This includes individual physicians working in IHS clinics. 2. Clinic applicants must list all the individuals affiliated to the group or clinic. Groups or Clinics must have at least one enrolled individual affiliated in order to be enrolled with the Colorado Medical Assistance Program. Please identify each affiliation by name and Medical Assistance Program Provider number. Individual providers cannot bill using a group number that is not listed below. Providers are required to notify Medical Assistance Program Provider Enrollment in writing of any change in affiliation information. 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Name Medical Assistance Program Provider # Contact Information If there are questions concerning this application, who may be contacted if the person submitting the application is not the applicant? Contact Name: ?t/ /zu -TL7 Contact Phone Number and/or Email Address: _! / l cJx t 1"Y) L [ 1 iny iU. 7 1'Y✓ Che) 54'66 09.5 6 er6/D/ Revised: November 20101 12 Signature Authorizations - Request for Original Signature Alternative Applicants who wish to authorize signatures by others must complete I authorize and request approval for the following alternatives to an original signature requirement for submission of paper claims to the Colorado Medical Assistance Program. Rubber stamp facsimile ❑ I authorize the use of a rubber stamp facsimile of my signature to be accepted in place of an original signature. I understand and agree that I am responsible for maintaining control of such a stamp and that the use of the stamp will conform to the requirements of the Colorado Medical Assistance Program. I further understand that I remain fully and totally responsible for the information contained on submitted claims. 4 Provider original signature: Signature stamp facsimile: Au orized agents I authorize the following individual(s) to sign claim forms submitted to the Colorado Medical Assistance Program as my authorized agent. I understand and agree that any claim forms signed under this authorization constitutes my personal confirmation of services rendered and that I remain solely responsible for the information contained on the claim form. I further understand that this authorization remains in effect until I notify the fiscal agent - in writing - of changes. /1 4 Provider original signature: r. J William F. Garda, Chair, Board of Weld County Commissioners Printed Name of Agent 1 I)eruwu JOf+ 2 M,3olhu`i�s 3 4 5 6 7 8 9 10 Original Signature of Agent I Revised: November 20101 13 Provider Participation Agreement All applicants must complete Note: All those providers with a current Colorado Medical Assistance Program Provider ID number, or those providers submitting an application to become a Colorado Medical Assistance Program Provider MUST EXECUTE AND RETURN this Provider Participation Agreement. PROVIDER PARTICIPATION AGREEMENT This Provider Participation Agreement ("Agreement") is entered into by and between the Colorado Department of Health Care Policy and Financing ("Department"), it's Fiscal Agent for the Colorado Medical Assistance Program, and (COLpsi 1l/ o F I,J�-L�7 Temg-o / (Provider Name) (Indicate' Pending' for new enrollment or provider number if previously enrolled) ("Provider"), collectively "the Parties." This Agreement is entered into in order to define Department expectations of providers who perform services and submit billing, transactions, and/or data to the Colorado Medical Assistance Program. This Agreement is also established to facilitate business transactions by electronically transmitting and receiving data in agreed formats; to ensure the integrity, security, and confidentiality of the aforesaid data; and to permit appropriate disclosure and use of such data as permitted by law. This Agreement is to be considered in conjunction with the Provider Enrollment Form, if necessarily completed. RECITALS A. The Colorado Department of Health Care Policy and Financing is the single state agency responsible for the administration of the Colorado Medical Assistance Program pursuant to Title XIX of the Social Security Act. B. The Fiscal Agent for the Colorado Medical Assistance Program has developed, on behalf of the Colorado Department of Health Care Policy and Financing, a paperless transaction system that will process Colorado Medical Assistance Program electronic transactions submitted through the designated electronic media. C. The contracted Fiscal Agent for the Colorado Department of Health Care Policy and Financing is responsible for administration of the Colorado Medical Assistance Program. Although the Fiscal Agent for the Colorado Medical Assistance Program operates the computer system translator through which electronic transactions flow, the Department retains ownership of the data itself. Providers access the pipeline network through various means, over which the transmission of electronic data occurs. Accordingly, providers are required to transport data to and from the Fiscal Agent for the Colorado Medical Assistance Program. D. Electronic transmission of any/all data shall be in strict accordance with the standards set forth in this Agreement and as defined by the Health Insurance Portability and Accountability Act of 1996 and regulations promulgated there under by the U.S. Department of Health and Human Services and other applicable laws, as amended. E. This Agreement is subject to modification, revision, or termination according to changes in federal or state laws, rules, or regulations. This Agreement will be deemed modified, revised, or terminated to comply with any change on the effective date of such change. F. This Agreement delineates the responsibilities of the Parties, and any agent, subcontractor, or employee of a Party, in regard to the Colorado Medical Assistance Program. As consideration for acceptance as an enrolled provider in the Colorado Medical Assistance Program, the Provider certifies and agrees to the terms and conditions set forth below. Revised: November 20101 14 Provider Participation Agreement - Continued All applicants must complete DEFINITIONS For the purpose of this Agreement: A. "Colorado Department of Health Care Policy and Financing" means the Colorado State governmental agency responsible for the administration of the Colorado Medical Assistance Program pursuant to Title XIX of the Social Security Act. B. "Standard" is defined in 45 C.F.R. §160.103. C. "Provider" refers to any health care provider with a current Colorado Medical Assistance Program Provider ID number or any health care provider submitting an application to become a Colorado Medical Assistance Program Provider. "Provider" also includes all agents, subcontractors, or employees of a Colorado Medical Assistance Program Provider. D. "Transaction" is defined in 45 C.F.R. §160.103. E. "Transactions and Code Set Regulations" mean those regulations governing the transmission of certain health claims transactions as promulgated by the U.S. Department of Health and Human Services in 45 C.F.R. Parts 160 and 162. PROVIDER PARTICIPATION A. Provider will comply with all applicable provisions of the Social Security Act, as amended; federal or state laws, regulations, and guidelines; and Department rules. Provider will limit the use or disclosure of information/data concerning Colorado Medical Assistance Program clients to the purposes directly connected with the administration of the Colorado Medical Assistance Program. B. Provider will accept full legal responsibility for all claims submitted under the Provider's Colorado Medical Assistance Program ID number to the Colorado Medical Assistance Program and will comply with all federal and state civil and criminal statutes, regulations and rules relating to the delivery of benefits to eligible individuals and to the submission of claims for such benefits. Provider understands that non-compliance could result in no payment for services rendered. C. Provider will request payment only for those services which are medically necessary or considered covered preventive services, and rendered personally by the Provider or rendered by qualified personnel under the Provider's direct and personal supervision. Claims will be submitted only for those benefits provided by health care personnel who meet the professional qualifications established by the State. Provider understands that any misrepresentation or falsification by another may result in fine and/or imprisonment under state or federal law. D. Provider will maintain records that fully and accurately disclose the nature and extent of benefits provided to eligible clients/patients in accordance with the regulations of the Department. Provider will maintain licensure and/or certification granted by the State licensing agency that regulates the services that are provided, and will make disclosure of ownership and provide access to medical records and billing information to the Department, or its designees, as required by federal and state laws and regulations. E. Provider records will be maintained for six (6) years unless an additional retention period is required under state or federal regulations, such as an audit started before the six (6) year period ended or based on a specific contract between the Provider and the Department. Revised: November 20101 15 Provider Participation Agreement - Continued All applicants must complete F. The US Department of Health and Human Services, the Department, or the State Attorney General's Medicaid Fraud Control Unit, or their designees, has the right to audit and confirm for any purpose any information submitted by the Provider. Provider agrees to furnish information about submitted claims, any claim documentation records, and original source documentation: including provider and patient signatures, medical and financial records in the Provider's office or any other place, and any other relevant information upon request. Any and all incorrect payments discovered as a result of an audit will be adjusted or fully recovered according to the applicable provisions of the Social Security Act, as amended, federal or state laws, regulations, and guidelines. G. Provider agrees to accept as payment in full, amounts paid in accordance with schedules established by the Department. No supplemental charges will be billed to the client, except for amounts designated as co - payments by the Department. Provider will not bill the client for any covered items or services that are reimbursable under the rules and regulations of the Department, or for any items or services that are not reimbursable but would have been had the Provider complied with the rules and regulations of the Department. All payments received or applied from any other sources will be recorded on the claim. H. Provider certifies that items and services provided will be available without discrimination as to race, color, religion, age (except as provided by law), sex, marital status, political affiliation, handicap, or national origin. Provider hereby certifies compliance with Section 504 of the Rehabilitation Act of 1973 which provides that, " no otherwise qualified handicapped individual...shall, solely by reason of his/her handicap, be excluded from participation in, be denied the benefits of, or be subjected to discrimination under any program or activity receiving federal financial assistance." If, at any time from the date of this agreement, the Department determines that Provider has failed to maintain compliance with any state or federal laws, rules, or regulations, Provider may be suspended from participation in the Medical Assistance Program, and may be subjected to administrative actions authorized by federal or state law or regulation, criminal investigation, and/or prosecution. J. Department payment by electronic funds transfer (EFT) and advisement by deposit notice or remittance statement represents Provider's confirmation that funds were accepted for services rendered and billed. K. Provider, and person signing the claim or submitting electronic claims on Provider's behalf, understands that failure to comply with any of the above in a true and accurate manner will result in any available administrative or criminal action available to the Department, the State Attorney General's Medicaid Fraud Control Unit, or other government agencies. The knowing submission of false claims or causing another to submit false claims may subject the persons responsible to criminal charges, civil penalties, and/or forfeitures. GENERAL ELECTRONIC DATA INTERCHANGE TERMS AND CONDITIONS (only applicable to those providers submitting and receiving data electronically) A. The Parties agree to submit claims and exchange data electronically using only those approved Transaction types and formats (versions) as selected by Provider within the Provider Enrollment Form. B. For electronic claims, Provider will ensure that all required provider and patient signatures, including, where applicable, appropriate signatures on behalf of the patient, and required physician certifications are on file in the Provider's office. C. Transactions/documents will be transmitted electronically either directly or through a contracted third -party service provider, such as a vendor, billing agent, or clearinghouse. Provider may modify its election to use, not use, or change a third -party service provider by updating the Provider Enrollment Form. Provider will be responsible for the costs of any third -party service provider with which it contracts, and will ensure that any third - party service provider contracted will properly institute and adhere to those procedures reasonably calculated to provide appropriate levels of security for the authorized transmission of data, and protection from improper access. No Party accepts responsibility for technical or operational difficulties that arise out of third -party service providers' business obligations and requirements that undermine the Transaction exchange between Provider and the Fiscal Agent for the Colorado Medical Assistance Program. Revised: November 20101 16 Provider Participation Agreement - Continued All applicants must complete D. The Parties will not change any definition, data condition, or use of a data element or segment in a Standard Transaction they exchange electronically, as per 45 C.F.R. §162.915. E. The Parties will not add any data elements or segments to the maximum defined data set, as per 45 C.F.R. §162.915. F. The Parties will not use any code or data elements that are either marked "not used" in a standard's implementation specification or are not in the standard's implementation specification(s), as per 45 C.F.R. §162.915. G. The Parties will not change the meaning or intent of a Standard's implementation specification(s), as per 45 C.F.R.§162.915. H. The Fiscal Agent for the Colorado Medical Assistance Program will accept Transactions from Provider according to the Provider Enrollment Form, but may subsequently deny a Transaction for further processing if the Transaction is not submitted using the data elements, formats or Transaction types set forth in the Provider Enrollment Form. The Fiscal Agent for the Colorado Medical Assistance Program may return Provider to a test status if Provider repeatedly submits Transactions that do not meet the criteria set forth in the Provider Enrollment Form or if Provider repeatedly submits inaccurate or incomplete Transactions to the Fiscal Agent for the Colorado Medical Assistance Program. Provider understands that the Fiscal Agent for the Colorado Medical Assistance Program or others may request an exception from the Transaction and Code Set Regulations from the U.S. Department of Health and Human Services. If an exception is granted, Provider will participate fully with the Fiscal Agent for the Colorado Medical Assistance Program in the testing, verification, and implementation of a modification to a Transaction affected by the change. J. Provider and the Fiscal Agent for the Colorado Medical Assistance Program agree to keep open code sets being processed or used in this Agreement for at least the current billing period or any appeal period, whichever is longer, as per 45 C.F.R. §162.925(c)(2). K. Transactions are considered properly received only after accessibility is established at the designated machine of the receiving Party. Once transmissions are properly received, the receiving Party will promptly transmit an electronic acknowledgement that conclusively constitutes evidence of properly received Transactions. Each Party will subject information to a virus check before transmission to the other Party. L. The Fiscal Agent for the Colorado Medical Assistance Program may publish data clarifications ("Companion Guides") to complement each Implementation Guide. HIPAA Implementation Guides are available at http://www.wpc-edi.com/hipaa/HIPAA 40.asp. Companion Guides are available on the Department's Web site at colorado.qov/hcpl*Providers*Provider Services*Specifications. ELECTRONIC CONFIDENTIALITY, PRIVACY AND SECURITY (only applicable to those providers submitting and receiving data electronically) A. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Regulations (45 C.F.R. Parts 160 and 164) apply to all health plans, health care clearinghouses, and health care providers that transmit protected health information in electronic transactions; and extends to any business associate working on behalf of a covered entity. As such, it is expected that all Parties will implement and maintain appropriate policies, procedures, and mechanisms to protect the privacy and security of protected health information that is maintained by, and transmitted between, the Parties. Revised: November 20101 17 Provider Participation Agreement - Continued All applicants must complete B. The Parties agree that any electronic protected health information furnished to one Party by any other Party will be used only as authorized under the terms and conditions of this Agreement and the Provider Enrollment Form, and may not be further disclosed. The Parties will establish appropriate administrative, technical, procedural, and physical safeguards to ensure the confidentiality, integrity, and availability of all electronic protected health information that is created, received, maintained, or transmitted as part of this Agreement. Provider will obtain satisfactory assurance and documentation thereof, as required by 45 C.F.R. §164.502(e), from any business associate with whom it contracts, and any subcontractors thereof, that all protected health information covered by this Agreement will be appropriately safeguarded. C. Provider agrees that in the event the Department determines, or has a reasonable belief that Provider has made or may have made disclosure of Colorado Medical Assistance Program client protected health information that is not authorized by this Agreement, the Provider Enrollment Form, or other written Department authorization, the Department, in its sole discretion, may require the Fiscal Agent for the Colorado Medical Assistance Program and/or Provider to: (a) promptly investigate and report to the Department determinations regarding any alleged or actual unauthorized disclosure; (b) promptly resolve any problems identified by the investigation; (c) submit a formal written response to an allegation of unauthorized disclosure; (d) submit a corrective action plan with steps designed to prevent any future unauthorized disclosures; and/or (e) return data to the Department. ASSIGNMENT OF AGREEMENT A. This Agreement is entered into solely between, and may be enforced only by the Parties. This Agreement shall not be deemed to create any rights in third parties or to create any obligations of the Parties to any third party. B. No Party may assign this Agreement without the prior written consent of the Department, and such consent may not be unreasonably withheld. MODIFICATIONS A. This Agreement contains the entire agreement between the Parties and supersedes any previous understanding, commitment or agreements, oral or written, concerning the electronic exchange of information/data. Any change to this Agreement will be effective only when set forth in writing and executed by all Parties. DISPUTES AND LIMITATION OF LIABILITY A. This Agreement will be interpreted consistently with all applicable federal and state laws. In the event of a conflict between applicable laws, the more stringent law will be applied. This Agreement and all disputes arising from or relating in any way to the subject matter of this Agreement will be governed by and construed in accordance with Colorado law, exclusive of conflicts of law principles. The exclusive jurisdiction for any legal proceeding regarding this agreement shall be in the courts of the State of Colorado and the Parties hereby expressly submit to such jurisdiction. B. Parties will use reasonable efforts to assure that the information — data, electronic files and documents supplied hereunder — are accurate. However, Provider shall indemnify, save, and hold harmless the Department, its employees and agents, against any and all claims, damages, liability and court awards including costs, expenses, and attorney fees incurred as a result of any act or omission by the Provider, or its employees, agents, subcontractors, or assignees pursuant to the terms of this Agreement. Revised: November 20101 18 Provider Participation Agreement - Continued All applicants must complete C. Notwithstanding anything herein to the contrary, no term or condition shall be deemed, construed or interpreted as a waiver, express or implied, of any of the immunities, rights, benefits, protections, or provisions, of the "Colorado Governmental Immunity Act", 24-10-101, et seq., C.R.S., as now or hereafter amended ("Immunity Act"), nor of the Risk Management self-insurance statutes at 24-30-1501, et seq., C.R.S., as now or hereafter amended ("Risk Management Act"). The Parties understand and agree that the liability of the State of Colorado, its departments, institutions, agencies, boards, officials and employees is controlled and limited by the provisions of the Immunity Act and the Risk Management Act, as now or hereafter amended. Any provision of this Agreement, whether or not incorporated herein by reference, shall be controlled, limited, and otherwise modified so as to limit any liability of the State to the above cited laws. In no event will the State be liable for any special, indirect, or consequential damages, even if the State has been advised of the possibility thereof. D. DISCLAIMER OF WARRANTIES. THE PARTIES HEREBY EXCLUDE ALL EXPRESS AND IMPLIED WARRANTIES, INCLUDING BUT NOT LIMITED TO THE IMPLIED WARRANTIES OF MERCHANTABILITY AND THE IMPLIED WARRANTY OF FITNESS FOR A PARTICULAR PURPOSE. THERE ARE NO WARRANTIES WHICH EXTEND BEYOND THE DESCRIPTION OF THE FACE OF THIS AGREEMENT. E. Provider warrants and represents that at the time of entering into this Agreement, neither Provider nor any of its employees, contractors, subcontractors or agents are identified on the HHS/OIG List of Excluded Individuals/Entities (available at http://www.oiq.hhs.gov/FRAUD/exclusions/listofexcluded.html). In the event Provider or any employees, subcontractors or agents thereof becomes an ineligible person after entering into this Agreement or otherwise fails to disclose its ineligible person status, Provider shall have an obligation to immediately notify the Department of such ineligible person status and within ten days of such notice, remove such individual from responsibility for, or involvement with the Providers business operations related to this Agreement. TERMINATION A. This Agreement shall remain in effect until terminated by any Party with not less than thirty (30) days prior written notice to the other Parties. Such notice shall specify the effective date of termination. In the event of a material breach of this Agreement by Provider, as determined by the Department, the Department may terminate the Agreement by giving written notice to the breaching Provider. The breaching Provider shall have thirty (30) days to fully cure the breach. If the breach is not cured within thirty (30) days after the written notice is received by the breaching Provider, this Agreement shall automatically and immediately terminate. B. This Agreement may be terminated by the Department if the contract between the Department and the Fiscal Agent for the Colorado Medical Assistance Program expires or terminates. Provider enrollment records will survive assignment of a new Department fiscal agent unless provider re -enrollment is explicitly initiated by the Department. TERM OF AGREEMENT A. This Agreement is effective for the entire term of enrollment. This Agreement shall continue until terminated. Revised: November 20101 19 Provider Participation Agreement - Continued All applicants must complete PROVIDER SIGNATURE PAGE NO PROVIDER APPLICATION, ENROLLMENT FORM, PROVIDER AUTHORIZATION FORM (if applicable), OR PROVIDER PARTICIPATION AGREEMENT WILL BE PROCESSED WITHOUT COMPLETION OF THIS PAGE I certify by my signature below that I am fully authorized to sign and execute this Agreement on behalf of Provider; and that I have read, understand, certify, and agree to all the statements made above in all parts of this Provider Participation Agreement. I further understand that any false claims, statements, documents, or concealment of material fact may be grounds for termination as a Colorado Medical Assistance Program Provider, and/or may be prosecuted under applicable federal and state laws. Provider By: Name: Title: Date: Provider #: / rovider/Provider Representative Signature (If the provider is an Intermediate Care Facility for the Mentally Retarded (ICF/MR), by signing, the ICF/MR also agrees to the stipulations in the addendum on the following page.) William F. Garcia Provider/Provider Representative Name (please print) Chair, Board of Weld County Commissioners MAR 1 1 2013 (Indicate' Pending' for new enrollment or provider number if previously enrolled) Revised: November 20101 20 Provider Participation Agreement - Continued for ICF/MR providers Only Only ICF/MR applicants/providers must complete this page Addendum for Intermediate Care Facility for the Mentally Retarded (ICF/MR) ONLY For Department of Health Care Policy and Financing staff only: For an Intermediate Care Facility for the Mentally Retarded (ICF/MR) provider, the length and conditions of this agreement are assigned by the Department of Health Care Policy and Financing in accordance with 42 C.F.R. Sections 442.12, 442.15(a), 442.16, 442.105, 442.109, and 442.110; and Centers for Medicare and Medicaid Services (CMS) Manual 11-107, State Operations Manual (SOM), Section 2141. Based on survey results, the status of certification and/or recommendations by the Department of Public Health and Environment (DPHE), and criteria in the cited federal regulations and SOM, the Department has determined the conditions of the agreement as specified in one of the following blocks: This agreement shall commence on and terminate on OR (only for ICF/MR provider with deficiencies but in compliance with survey Conditions of Participation) This agreement shall commence on and terminate on subject to automatic cancellation 60 days after the projected correction date in the Plan of Correction (PoC) accepted by DPHE for the deficiencies identified by DPHE in the most recent survey prior to the commencement date. Automatic cancellation shall occur if all deficiencies are not corrected, unless the Department and DPHE in their sole discretion determine that the ICF/MR has made substantial effort and progress in correcting deficiencies. This determination is not subject to appeal. Date of most recent survey prior to commencement date: Projected completion date of Plan of Correction: Automatic cancellation date (60 days after projected completion of PoC) Provider By: ICF/MR Provider/Provider Representative Signature Name: ICF/MR Provider/Provider Representative Name (please print) Title: Provider #: Date: Revised: November 20101 21 Payment Reporting and Publication Email Preference All applicants must complete Provider Claim Report (PCR) Information The following information will allow the Colorado Medical Assistance Program to prepare your PCR in a manner that is helpful for you. Please indicate your preferences. ❑ My claims will be submitted by (through) a billing agent or clearinghouse who will receive the PCRs. (Skip remaining Provider Claim Report questions.) Sort sequence preference In what order do you want claims listed on the PCR? If no selection is made, claims will be sorted in order by client last name. ❑ Client last name (N) ❑ Date of Service (D) ❑ Client State Medical Assistance Program ID (I) ❑ Patient account/Invoice number (A) ❑ Rendering Provider Number (B) (may be useful for group practices) ❑ Rendering Provider Name (P) (may be useful for group practices) Reporting in process (suspended) claims How do you want in -process (suspended) claims reported on the PCR? If no selection is made all suspended claims will be listed. ❑ List all suspended claims (A) ❑ List only new suspended claim (0) ❑ Do not list suspended claims (N) (not recommended) Publication Email Notification Preference The Colorado Medical Assistance Program communicates important notices (including time -sensitive information), updates, billing instructions and bulletin links via email as soon as the information is available. Providers are responsible for ensuring that the fiscal agent has their current email address on file. The Colorado Medical Assistance Program is not responsible for undeliverable notifications due to incorrect email addresses. All publications are available in the Provider Services section of the Department's Web site at colorado.gov/hcpf. Publication Email Notification Preference (Please check one): Please email notifications and bulletin links to me. ❑ Another provider will receive email notifications and bulletin links on my behalf. (I understand that lam responsible for obtaining the information from this provider and that I will not receive any email notifications from the Colorado Medical Assistance Program). ❑ None (I understand that I am responsible for retrieving publications from the Web site and that I will not receive any email notifications from the Colorado Medical Assistance Program). Provider Email Address: �pyi-i darn toeLrl.3o" r'brr, Please note that only one email address per provider may be on file. Revised: November 20101 22 Please return the completed Provider Enrollment Form, Provider Authorization Form (if applicable), and executed Provider Participation Agreement to the following address: Colorado Medical Assistance Program Provider Services P.O. Box 1100 Denver, CO 80201-1100 Revised: November 20101 23 Doctorate Level Psychologist (37) Licensed Mental Health Professional (under Doctorate Level) (38) Appendix A - Reference Information for Services Identification Provider types and licensure requirements Practitioners and Practitioner Groups The Internal Revenue Service requires that payments made to an individual be reported to the individual's social security number. All individual practitioners must complete a provider application and be enrolled. If an enrolled individual wants payments made to a corporation, partnership or sole proprietorship (group), the group must be enrolled and have a group provider number. The group provider number must be identified as the billing provider on all claims. Services/Providers Licensure & certification submission requirements Certified Nurse -Midwife (22) Clinic, Professional Corporation, Partnership, or Sole Proprietorship (16) Optometrist (07) Physician (MD) (05) and (DO) (26) Podiatrist (06) Non -Physician Practitioner Group (25) Attach state nursing license and certificate from American College of Nurse -Midwives. At least one Medical Assistance Program -enrolled practitioner must be listed. Requires CLIA certificate for laboratory services if applicable. Attach state optometry license. Attach state medical license and specialty certification if applicable. Requires CLIA certificate for laboratory services if applicable. Attach state podiatry license. Requires CLIA certificate for laboratory services if applicable. At least one Medical Assistance Program -enrolled non -physician practitioner must be listed. Non -Physician Practitioners — Requiring on -premise physician supervision Requires on -premise physician supervision when services are provided and payments must be made to a physician or clinic. Must identify physician supervisor by name on the separate "Non -Physician practitioners requiring on -premise physician supervision" form. Services/Providers Licensure & certification submission requirements Registered Nurse (24) Attach state nursing license. Non -physician Practitioners - Special direct payment requirements By enrolling for direct payment you are certifying that services are not provided in the course of employment, otherwise payments must be made to a physician or clinic. Services/Providers Licensure & certification submission requirements Audiologist (19) Attach copy of Colorado Audiology License Certification from the American Speech and Health Association or the American Board of Audiology. Proof of registration with State Audiology and Hearing Aid Provider Registration Office. If providing services in the course of employment, payments must be made to a physician or clinic. Certified Registered Nurse Anesthetist (40) Attach state nursing license and certification by the Council on Nurse Anesthetists. If providing services in the course of employment, payments must be made to a physician or clinic. Licensed: Attach Colorado Psychologist License. Unlicensed: Cannot enroll. Attach state social work license or professional counselor license and proof of education. If providing services in the course of employment, payments must be made to a physician or clinic. Revised: November 20101 A-1 Appendix A - Reference Information for Services Identification - Continued Provider types and licensure requirements Non -Physician Practitioners — Special direct payment requirements By enrolling for direct payment you are certifying that services are not provided in the course of employment, otherwise payments must be made to a physician or clinic. Services/Providers Licensure & certification submission requirements Nurse Practitioner (41) Occupational Therapist (28) Physical Therapist (17) Physician Assistant (39) Speech Therapist (27) Attach state nursing license + one of the following: Pediatric Nurse Practitioner Certificate from National Certification Board of Pediatric Nurse Practitioners or Family Nurse Practitioner Certificate from American Nurse Association. If providing services in the course of employment, payments must be made to a physician or clinic. Attach state occupational therapy license. If providing services in the course of employment, payments must be made to a physician or clinic. Attach state physical therapy license. If providing services outside the course of employment only general physician supervision is required. If providing services in the course of employment, payments must be made to a physician or clinic. Attach state medical license. If providing services outside the course of employment only general physician supervision is required. If providing services in the course of employment, payments must be made to a physician or clinic. Attach American Speech and Hearing Association certification. If providing services in the course of employment, payments must be made to a physician or clinic. Dental providers and dental groups The Internal Revenue Service requires that payments made to an individual be reported to the individual's social security number. All individual dental providers must be enrolled. If an enrolled individual wants payments made to a corporation, partnership or sole proprietorship (group), the group must be enrolled and have a group provider number. All claims must identify the group provider number as the billing provider on all claims. Services/Providers Licensure & certification submission requirements Dental Clinic, Professional Corporation, Partnership, or Sole Proprietorship (47) Dental clinic ownership must be a licensed dentist or dental hygienist, a political subdivision, or a non-profit corporation. In state dental clinic owners must have a current/active/valid Colorado dental or dental hygienist license. Attach a copy of the license. A non-profit corporation must be in good standing and submit a copy of the Certification of Good Standing issued by the Colorado Secretary of State. At least one Medical Assistance Program enrolled dentist or dental hygienist must be associated with the clinic. Attach a copy of the dental license. Dentist (04) Attach a copy of state dental license. Orthodontist (04), Specialty (63) Attach a copy of state dental license and certificate of graduation from an American Dental Association Accreditation Commission accredited program in orthodontics. Revised: November 20101 A-2 Appendix A - Reference Information for Services Identification - Continued Provider types and licensure requirements Dental providers with special direct payment requirements Licensed dental hygienists shall be directly reimbursed for unsupervised dental hygiene services rendered to Medical Assistance Program enrolled children effective February 1, 2002. Those licensed dental hygienists requesting direct reimbursement must complete a provider enrollment form. The dental hygienist employed by a dentist, clinic or institution shall not submit claims individually and shall submit claims under the employer's assigned Medical Assistance Program provider number. Dental Hygienist (04), Specialty (66) Attach a copy of state dental hygiene license. Medical Services Facilities (other than nursing facilities) Services/Providers Licensure & certification submission requirements Ambulatory Surgical Center (44) Hospital, General (01) and Mental (02) Attach state license and certificate (Department of Public Health and Environment) and Medicare certification. Attach state license, certificate (Department of Public Health and Environment), Medicare certification, CLIA certification and proof of liability/fidelity insurance. In state hospitals require contract with Colorado Department of Health Care Policy and Financing. Medical Services Facilities (other than nursing facilities) Services/Providers Licensure & certification submission requirements Independent Laboratory (12) X-ray Facility (Freestanding) (49) Attach CLIA certification (Department of Public Health & Environment) and Medicare certification. Attach state Certification and Evaluation Report (Department of Public Health and Environment), American College of Radiology certificate and American Registry of Radiologic Technologists certificate, and Medicare certification. Mammography providers must also attach Mammography Quality Standards Act certification and US Department of Health and Human Services survey approval. Revised: November 20101 A-3 Appendix A - Reference Information for Services Identification - Continued Provider types and licensure requirements Nursing and Residential Facilities Services/Providers Licensure & certification submission requirements Intermediate Nursing Facility (21) Skilled Nursing Facility (20) Psychiatric Residential Treatment Facility (30) Residential Child Care Facility (52) Physician (MD) (05) and (DO) (26) Doctorate Level Psychologist (37) MA Psychologist (38) (under Doctorate Level) Physician Assistant (39) Nurse Practitioner (41) Attach state license (Department of Public Health & Environment). Requires contract with Colorado Department of Health Care Policy and Financing. Attach state license and certificate (Department of Public Health and Environment). Requires contract with Colorado Department of Health Care Policy and Financing. Medicare certification required for Swing Bed facilities. Attach state license (Department of Human Services) and DPHE certification. Attach state license (Department of Human Services). Attach state medical license and specialty certification if applicable. Requires CLIA certificate for laboratory services if applicable. Attach state psychologist license. Attach state clinical social worker license, marriage and family therapist license or professional counselor license. (On premise physician supervision is waived for mental health professionals providing mental health services in Residential Child Care Facilities.) Attach state medical license. Attach state nursing license and documentation of registration as an advance practice nurse with prescriptive authority. If providing services in the course of employment, payments must be made to a physician or clinic. Prepaid Health Plan Providers Services/Providers Licensure & certification submission requirements Contracted Health Maintenance Organization or Prepaid Health Plan (capitation) (23) Contracted Mental Health Assessment and Requires contract with Colorado Department of Health Care Policy Service Agency (capitation) (31) and Financing. Attach state license (Division of Insurance). Requires contract with Colorado Department of Health Care Policy and Financing. Attach state license (Division of Insurance). Clinics, Agencies and Specialized Services Providers Services/Providers Licensure & certification submission requirements Community Mental Health Center (35) Certified Public Health Clinic (16) Contracted Family Planning Clinic (29) Attach state license (Department of Public Health and Environment) and certificate. Requires contract with Colorado Department of Health Care Policy and Financing. Attach state license (Department of Public Health and Environment). Note: Individual service providers (nurses and nurse practitioners) and the agency's medical director (physician) must be enrolled. Attach state license (Department of Public Health & Environment). Requires contract with Colorado Department of Health Care Policy and Financing. Individual service providers (nurses and nurse practitioners) must be enrolled. Revised: November 20101 A-4 Appendix A - Reference Information for Services Identification - Continued Provider types and licensure requirements Clinics, Agencies and Specialized Services Providers Services/Providers Licensure & certification submission requirements Federally Qualified Health Center (32) Home Health Agency (10) Dialysis Center (33) Developmental Evaluation Clinic (46) Hospice (50) Outpatient Substance Abuse Treatment Clinic (16) Rural Health Clinic (45) Rehab Agency (48) Attach approval letter from US Department of Health and Human Services or CMS, and Medicare certification. Note: Individual service providers (nurses and nurse practitioners) and the agency's medical director (physician) must be enrolled. Attach state certificate (Department of Public Health and Environment) and Medicare certification specifically for Home Health. Attach state license and certificate (Department of Public Health and Environment) and Medicare certification. Attach state license and certificate (Department of Public Health and Environment). The Medical Director must be enrolled. Attach state license and certificate (Department of Public Health & Environment) and Medicare certification. Attach state license (Colorado Department of Human Services — Alcohol & Drug Abuse Division (ADAD) or the Division of Behavioral Health (DBH)). Attach Medicare certification (indicating Freestanding), Medicare rate sheet and provider's cost report. Note: Individual service providers (nurses and nurse practitioners) and the agency's medical director (physician) must be enrolled. Comprehensive Outpatient Rehabilitation Facility (CORF): Attach Medicare certification. A CORF must have at least one Medical Assistance Program enrolled MD or DO listed. Individual service providers must be enrolled. Practitioner: Must have at least one Medical Assistance Program enrolled physical, occupational, or speech therapist listed. Individual service providers must be enrolled. Retail Providers Services/Providers Licensure & certification submission requirements Optical Office (Optician) (08) Oxygen Supplier for Nursing Facilities (14) Pharmacy (09) Supply/Medical Equipment Supplier (14) Attach business license (sales tax certificate). Enroll as a Supply provider. Attach state pharmacy license and National Council of Prescription Drug Programs certificate. Pharmacies that are Indian Health Service or Tribally -Operated do not require a license however, federal IHS/Tribal pharmacy requirements must be met. Out of state providers must complete and submit the 'Out of State Pharmacy Requirements' letter. Attach business license (sales tax certificate). Medicare Accreditation Certificate or letter required. Attach copy. Out of state providers must complete and submit the 'Out of State Durable Medical Equipment Provider Requirements' letter. Revised: November 20101 A-5 Appendix A - Reference Information for Services Identification - Continued Provider types and licensure requirements Providers enrolled for Medicare crossover benefits only Services/Providers Licensure & certification submission requirements Chiropractor (18) Non -Physician Mammography Practitioners (18) Attach current state chiropractic license and proof of Medicare participation. Attach US Department of Health & Human Services, or CMS certification and registration by the American Registry of Radiologic Technologists or American College of Radiology, and proof of Medicare participation. Community Based Services Providers Services/Providers Licensure & certification submission requirements Community -based Services for the Elderly, Blind, Disabled, Mentally III, Persons Living With AIDS, Children's Home and Community Based Services, etc. (34) Community Services for the Developmentally Disabled (36) Colorado Choice Transitions (CCT) Demonstration Program (34), (36) School District (51) Attach state license (Department of Public Health & Environment), when applicable. Enrollment requires approval from the Colorado Department of Health Care Policy and Financing. Attach state license (Department of Public Health & Environment), when applicable. Enrollment requires approval from the Colorado Department of Human Services, Division of Developmental Disabilities. Enrollment requires approval from the Colorado Department of Health Care Policy and Financing. Caregiver Education: Attach site survey (Department of Public Health & Environment) and proven model to organize an informal support network into a cohesive caregiver team. Community Transition Services, Home Delivered Meals, -Intensive Case Management, Peer Mentorship, Transitional Specialized Day Rehabilitation Services: Attach site survey (Department of Public Health & Environment). Dental: Attach a copy of state dental license. Enhanced Nursing Services: Attach class A license and site survey (Department of Public Health & Environment). Home Modifications: Attach a copy of contractor's license, a list of counties served, and proof of insurance. Transitional Behavioral Health Supports, Transitional Substance Abuse Counseling: Submit proof of certification or licensure. Vision: Attach state optometry license. Developmentally Disabled, Supported Living Services: requires approval from the Colorado Department of Human Services, Division of Developmental Disabilities. None Transportation Providers Services/Providers Licensure & certification submission requirements Emergency Transportation (13) Non -Emergency Transportation (13) Air Transportation (13) Attach County ambulance permit and Medicare certification. Attach Public Utilities Commission certificate. Attach licensed accreditation from DPHE pursuant to CRS §25.23.5- 307. Attach Accreditation of Medical Transport Systems (CAMTS). Revised: November 20101 A-6 Form (Rev. Department Internal 1111-U Member 2011) of the Treasury Revenue Service Request for Taxpayer Identification Number and Certification Give Form to the requester. Do not send to the IRS. jMint or type Sad See Specific Instructions on page 2. Name (as shown on your income tax return) County of Weld Business name/disregarded entity name, it different from above Check appropriate box for federal tax classification: TrusVestate ► • Individual/sole proprietor Ii C Corporation iii S Corporation im Partnership ❑ ❑ Limited liability company. Enter the tax classification (C=S C corporation, Scorporation, P=partnershlp) Q Other (see instructions) iii- Government •Exempt payee Address (number, street, and apt. or suite no.) 1150 "O" Street, P.O. Box 758 Requester's name and address (optional) City, state. and ZIP code Greeley , CO 80632 List account number(s) here (optional) TMTnvnntnar Ness: •I..� __ -..n Enter your TIN in the appropriate box. The TIN provided must match the name given on the "Name" line to avoid backup withholding. For individuals, this is your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a 71N on page 3. Note. If the account is in more than one name, see the chart on page 4 for guidelines on whose number to enter. Part II Certification I Social security number Employer identification number 8 4 6 0 0 0 8 1 3 Under penalties of perjury, I certify that: 1. The number shown on this form Is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding, and 3. I am a U.S. citizen or other U.S. person (defined below). Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the Instructions on page 4. Sign Here Signature of �! U.S. person ► General Instructions Section references are to the Internal Revenue Code unless other sew noted. Purpose of Form A person who is required to file an information return with the IRS must obtain your correct taxpayer identification number (TIN) to report, for example, income paid to you, real estate transactions, mortgage interest you paid, acquisition or abandonment of secured property, cancellation of debt, or contributions you made to an IRA. Use Form W-8 only if you are a U.S. person (including a resident alien), to provide your correct TIN to the person requesting it (the requester) and, when applicable, to: 1. Certify that the TIN you are giving is correct (or you are waiting for a number to be issued), 2. Certify that you are not subject to backup withholding, or 3. Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income. Date" j-5-aoi3 pote. ester gives you a form other than Form W-9 to request /your TIN, you m t use the requester's form if it is substantially similar to this Form W-9. Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are: • An individual who is a U.S. citizen or U.S. resident alien, • A partnership, corporation, company, or association created or organ¢ed in the United States or under the laws of the United States, • An estate (other than a foreign estate), or • A domestic trust (as defined in Regulations section 301.7701-7). Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generaly required to pay a withholding tax on any foreign partners' share of income from such business. Further, In certain cases where a Form W9 has not been received, a partnership is required to presume that a partner is a foreign person, and pay the withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business In the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid withholding on your share of partnership income. Cat. No. 10231X Form W-9 (Rev. 12-2011) Agency ID UHA State of Colorado AUTHORIZATION AGREEMENT FOR AUTOMATIC DEPOSITS (ACH CREDITS) Check one: New a Change ❑ I (we) hereby authorize the Department of Health Care Policy & Financing, State of Colorado, hereinafter called STATE, to initiate credit entries and, if necessary, reverse any incorrect EFT credit entries made in error to our bank account indicated below. APPLICATION (Payment type) LEGAL NAME DBA NAME MEDICAID TYPE (34) MEDICAID PROVIDER # Look y o4 tJeld Complete one of the following (EIN or SSN) but not both FEDERAL EIN NUMBER (Corporation, partnership, trust, sole proprietor, etc.) or SOCIAL SECURITY NUMBER (Individual or sole proprietor) ADDRESS CITY, STATE, ZIP /150 O 3+'rcel- PO. t -t 7S? l0'04 3:z) 6redet Co £G(e3/ BANK NAME BANK ADDRESS CITY, STATE, ZIP BANK DEPOSITORY TRANSIT NUMBER ACCOUNT NUMBER DEPOSITORY INFORMATION l� Ce-c:3 f 4e go 7i4.'//C Wt?3 f ?/&Al 3sf" 4vc. Girt -C/6'7 Co 80434 /D%Z.DDoc '74, 4/'/ L B o c 4/3 7)— TYPE OF BANK ACCOUNT (CHECK ONE) CHECKING El SAVINGS A ach voided check or bank letter Attach bank letter This agreement is to remain in full force and effect until the STATE has received written notification from the PAYEE of its termination in such time and manner to afford STATE and FINANCIAL INSTITUTION a reasonable opportunity to act on it. It is the responsibility of the PAYEE to fill out a new agreement if the PAYEE changes banks or accounts. Date 3 - - /3 Authorized Signature Phone number Q'7o % J — /55—/ Title Fs M4n4`c>l (,A c4 (0,41117 . u/ ffii4“- Authorized Signature Title For fiscal agent use only Initials: Date: Revised: November 20101 PAY TO THE ORDER OF MEMO OFFICE OF THE COUNTY TREASURER P.O. BOX 458 GREELEY, CO 80632-0458 970-353-3845 WELLS FARGO BANK WEST, N.A. 2164 35TH AVENUE GREELEY, CO 80634 23-7/1020 $ VOID IF NOT CASHED WITHIN 90 DAYS AUTHORIZED SIGNATURE II'05526511■ I:i02000076i: 442 80043751 OFFICE OF THE COUNTY TREASURER 055265 DOLLARS 055265 \10.,\ cork Ems5.04%**>. PAP'3; OFFICE OFTHE COUNTYTREASURER 055265 9 4 9 9 M Hello