Ocean Partnership for Children requires providers referred to work with the youth and families we serve to have a Memorandum of Understanding (MOU), Professional Agreement, or Vendor Agreement. The purpose of such is to outline expectations of service delivery for both parties. If you are interested in arranging a MOU, please follow the steps below. Incomplete applications will not be considered.
The following documents need to be completed or provided as indicated below and included in the application package and sent to firstname.lastname@example.org:
- MOU or Agreement – Please review and complete ONE of the following documents based on the type of services provided:
- MOU – To be completed by Medicaid providers that offer Medicaid services such as IIC, BA, IIH, and/or ISS services. Professional or vendor agreement does not need to be completed in addition to the MOU for non-Medicaid services. Non-Medicaid services should be included in MOU on page 6, section ‘Non-Medicaid/Flexible Funded Services and Rates’.
- Professional Agreement – To be completed by non-Medicaid providers that offer services such as evaluations/assessments, therapeutic interventions, etc.
- Vendor Agreement – To be completed by non-Medicaid providers that offer services that are not therapeutic in nature such as recreation, transportation, etc.
- W-9 – Please complete and include in application packet.
- Agency or Individual Profile – Please complete and include in application packet.
- Staff List Template – Please complete and include in application packet.
- OPC 6032 Memo – Please review and initial MOU/agreement (page 2) to acknowledge receipt.
- Insurance and Policies – Please provide a copy of your current comprehensive general liability and automobile liability insurance (if providing transportation to clients in the course of business).
- Agency Employee Background Check Policy – Please provide a copy of current agency employee background check and driving record (if providing transportation to clients in the course of business) policy.
*Electronic signatures are required on MOUs, agreements, and W-9 forms.*
The following information/documents are important to delivery of services per the MOU/agreement:
- Provider Report to the Child Family Team – To be completed for non-Medicaid authorized services and sent with an invoice to email@example.com monthly for each referred youth.
- Sample Provider Report to the Child Family Team
- Sample Invoice – Guidance for non-Medicaid providers to bill OPC for authorized services.
- Summary of OPC Contracted Providers’ Roles and Responsibilities
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Please send completed application packets and questions to firstname.lastname@example.org. Incomplete applications will not be considered.
Please note not all MOU/agreement applications will be honored or finalized. Decisions are based on compliance with MOU/agreement expectations as well as need and demand for services.