Initial Letter Pre-Signature 2023

Service Provider Name *

Dear (Prospective Service Provider)

Thank you for assisting the Middlesex County Care Management Organization (CMO) with providing quality care and services to children and families of Middlesex County. As part of our process working with community service providers, please attach the fully completed documents below:

Memorandum of Understanding (MOU)
Service Provider Criminal Background Check Agreement Statement Form
Mandatory Wrap Around Training Acknowledgement Statement Form
Provider Contact Information Form

Outlined below is the process to complete the Agreement between Coordinated Family Care and your organization.

All required forms and items are to be uploaded to this checklist :

1. Provider Contact Information Form:*

2. CFC Universal MOU (Memorandum of Understanding): *

3. Service Provider Criminal Background Check Agreement Statement Form and Mandatory Wraparound Training Acknowledgement Statement: *

4. Submit copy of current Credentials/Licensure for all supervising staff members only:*

4a. Submit copy of current Credentials/Licensure for all supervising staff members only: *

5. Submit proof of a Criminal Background Check report with cleared results (within 1 year) for all supervising staff members:*

6. Send a copy of your current universal staff listing (include certifications, licenses, language, and specialties): *

6a. Send a copy of your current universal staff listing (include certifications, licenses, language and specialties): *

7. Send a copy of current agency comprehensive general and professional (malpractice) liability, property damage and automobile liability insurance policy (if providing transportation to families or youth) - be sure it meets all MOU requirements. Coordinated Family Care must be listed as a certificate holder. Your required insurance coverage minimum is: Each Claim: $1,000,000.00 General Aggregate/Aggregate: $3,000,000.0**

8. Send a copy of your Medicaid Provider Approval Letter (if applicable) If you offer multiple services, please be sure to include the service and corresponding number.*

8a. Send a copy of your Medicaid Provider Approval Letter. If you offer multiple services, please be sure to include the service and corresponding number. *

9. Complete your provider profile on the Middlesex Resource Net site. * www.middlesexresourcenet.org*

9a. In order to complete the MOU request, you must first complete your provider profile on the Middlesex County Resource Net .

https://www.middlesexresourcenet.org/

If you have questions about how to create your profile please reach out to Lisa Murray-Williams at lmurray@coordinatedfamilycare.org. Thank you!

10. Send a copy of your Services and Rates on your agency's letterhead. Please include: Medicaid services, service codes, rates, and any other services your agency provides (Flex fund services, Outpatient, Counseling, Groups, etc. with all corresponding rates. Also, be sure to include Sliding Scale Rates (for all flex-fund services), accepted forms of payment - including major insurance. *

Coordinated Family Care will then:

Review, sign, and return a copy of the fully executed MOU.

Once again, thank you for your time and commitment to the children and families of Middlesex County. Coordinated Family Care looks forward to a successful partnership for everyone involved. If you have any concerns, please feel free to contact providers@coordinatedfamilycare.org

Lisa Murray-Williams, - MS Resource Development Manager

CC: Jarrett Lynn, Chief Operating Officer, Coordinated Family Care