/tr>
ADDENDUM PROVIDER ENROLLMENT - PT 11

ADDENDUM PROVIDER ENROLLMENT - PT 11
SPECIALTY MENTAL HEALTH CRISIS INTERVENTION SERVICES 118



Mental Health Crisis Intervention Services


Telephone Crisis

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________

Walk-in Crisis

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________

Mobile Crisis, Individual Delivered

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________






Mobile Crisis, Team Delivered

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________

Crisis In-Home Support

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________

Medical Mobile Crisis, Team Delivered

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________

Crisis Residential

Effective Date of Enrollment: __________________________________

Date of Site Visit: __________________________________________

Certificate of Compliance (License) Number: _____________________

Certificate of Compliance effective date: ________________________

Ending Date of Certificate of Compliance: ________________________




Funding Source

HealthChoices Only: [ ] Fee-For-Service: [ ] Both: [ ]

The following additional attachments are needed to complete package:

- Letter of Support from County
- Certificate of Compliance (with attached letter)
- Two Provider Agreements with original signatures