Facility Data Intake Form

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Section 1 instructions: Please complete all fields below for the facility and check the appropriate facility type. Facility name: Type: Ancillary Behavioral health Hospital MLTSS Name doing business as (if applicable): Primary contact name: Primary contact email: Primary contact phone: Pay to street address: Building or suite number: City, state ZIP: Phone number: Section 2 instructions: Please complete each section below for all locations including applicable waivers, TIN/EIN, NPI and Medicaid ID information. (Make additional copies, if needed.) Facility name (as it will appear in a provider directory) Street address Building or suite number City State ZIP code County Phone number with area code Taxonomy code Facility type (i.e., skilled nursing facility, hospice, durable medical equipment) TIN/EIN number NPI number Medicaid ID Page 1 of 6

Adult care home/assisted living facility Adult care home home plus Adult care home/nursing facility mental health (NFMH) facility Adult care home/nursing facility (SNF/NF) Adult care/home residential health care facility Assisted living facility/services Assistive technology Attendant care services Audiology and hearing services Autism specialists Behavioral health professional and substance abuse services, evaluations, testing, assessments, med management and/or therapies Cognitive therapy Community transition services Comprehensive support Day support Page 2 of 6

Dental services Enhanced residential care Enrollee/caregiver training Family adjustment counseling Family planning services Financial management services Health department services Health maintenance monitoring Home care/services Home health agency/services Home modification services Home-delivered meals service Hospice Hospital/longer term acute care hospital (LTACH) Independent living counseling Intensive individual support Intermittent intensive medical care service Page 3 of 6

Laboratory Long-term community care attendant Medical equipment and supplies Medical services technician Medical alert rental Medication reminder services Mental health, substance abuse, and intellectual/developmental disability services Money follows the person transition coordination Nursing evaluation visit/delegation visit Nutritionists Parent support and training Personal care agency/custodial support Personal emergency response system rental Personal emergency response systems and installation Personal services Personal services agency directed Podiatry services Page 4 of 6

Radiology services diagnostic and therapeutic Rehabilitation facility Rehabilitative home services Renal dialysis center Residential supports Respite care Skilled nursing and/or long-term rehabilitation services Sleep cycle support Specialized home nursing services Specialized medical care LPN/RN Specialized medical care/medical respite Specialized medical equipment and supplies Supportive employment services Targeted case management Therapy occupational Therapy speech Page 5 of 6

Therapy physical Transitional services Transportation Tribe/tribal organization/urban Indian organization/indian health services Vision services Wellness monitoring Work program assistive services Work program independent living counseling Telemedicine (primary care, medical, psych-telehealth) *Please list the service types related to telemedicine in the fields provided. Please add any unlisted services and indicate location. ACKS_18207286 Page 6 of 6

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