Take Charge! Existing ContractorContact Information Form

Take Charge! Existing Contractor

Contact Information Form

Please fill in the requested information below.

***This form is for existing contractors only! Clients and prospective contractors should reach out to Take Charge! directly. ***

Complete the following fields with the current information for your contract. If you have multiple sites you will need to complete a form per site. This form provides information that will assist in processing invoices, referring clients to your facility for services, and obtaining data.

If you have any questions about this form, please call or email Take Charge! at 1-888-669-5934 or CancerPCP@health.ok.gov.

Per the Terms of the Contract:

Information must be completed and returned to the Take Charge! contractor within 30 days of issuance of your purchase order.

No invoices will be processed for payment until all applicable items listed in the Administrative Section of your contract have been received

Submit renewal of medical licenses, malpractice insurance, and certifications to the OSDH within 30 days of renewal date

Submit any updated contract information through this form to the Take Charge! Program when ANY change occurs in staff, location, and/or phone number within 14 workdays of the change.

Select the current fiscal year*

Select

Legal Name of Facility*

Enter the legal name of your facility

Doing Business As Facility Name (if applicable)

Tax ID Number (EIN or FEIN)

Physical Address*

City*

Select

State*

Zip*

County*

Select

Main Phone Number*

Phone

Main Fax Number

Phone

Select all of the services provided at the facility location*

This information will be reviewed to assure we have provided the correct reimbursement attachment with your contract.

Select

Mailing Address (Leave blank if same as physical address)

Mailing City

Select

Mailing State

Mailing Zip

Website Address

Select the services which are subcontracted for Take Charge! clients. A copy of the subcontract must be uploaded to this form in the documents upload section.*

Select

Select all the days this facility site is open*

Select

What hours are client services provided on Monday?

What hours are client services provided on Tuesday?

What hours are client services provided on Wednesday?

What hours are client services provided on Thursday?

What hours are client services provided on Friday?

What hours are client services provided on Saturday?

What hours are client services provided on Sunday?

Appointment Contact Information

Appointment Contact*

Enter the name of the person that Take Charge! client should talk to to schedule a Take Charge! appointment. If anyone at your facility can schedule appointments, please write "any appointment scheduler" in the field; The contact person's name will be appear on the Take Charge! available facilities list.

Appointment Phone Number*

This should be the phone number that clients will call to schedule appointments. This phone number will be listed on the Take Charge! available facilities list.

Phone

Appointment Phone Extension Contact 1

This should be the phone number extension that clients will call to schedule appointments. This phone number will be listed on the Take Charge! available facilities list.

Email Address for Appointment Contact*

Appointment Fax Number Contact 1

Phone

Do you have another person that can assist with making appointments at your facility?*

Select

Name of additional staff that can assist with scheduling Take Charge! Appointment

Appointment Phone Number for Additional Staff

Phone

Appointment Phone Extension for Additional Staff

Phone

Email Address of additional staff that can assist with scheduling Take Charge! Appointment

Clinical Contact Person*

This is the person that Take Charge! will call when there appears to be a clinical issue.

Clinical Phone Number*

Phone

Clinical Phone Extension

Clinical Email Address*

Clinical Fax Number

Phone

Billing Contact Person*

Take Charge! will work with the person listed in this field for all billing issues. As a reminder if you use a billing company, please enter their information here. Take Charge! will required a signed confidentaility agreement for an outside billing company. It is your responsibility as the contractor to obtain the signed form, as the billing contractor is your contractor, not Take Charge!'s contract.

Billing Address (Same as above?)*

Select

Billing Address (If not same as above)

Billing City

Select

Billing State

Billing Zip

Billing Email Address*

Billing Phone Number*

Phone

Billing Extension

Billing Fax Number

Phone

Select the staff type (that is listed in this form) who is responsbile for accessing secure portal (Med-IT) or Box.com*

A current confidentiality agreement must be uploaded to this form. This individual will have direct access to Private Health Information (PHI), with no restricted access.Email CancerPCP@health.ok.gov if you need to request a form.

Select

Confidentiality Agreement Signature Person(s)*

Please include name and email for all who need access to Box.com or Med-IT. These individuals will have direct access to Private Health Information (PHI), with no restricted access. These people will be asked to complete a Confidentiality Agreement.

Quality Assurance Manager Name*

Quality Assurance Manager Phone Number*

Phone

Quality Assurance Manager Extension

Quality Assurance Manager Fax Number

Phone

Quality Assurance Manager Email Address*

Data Request Contact Name*

Take Charge! will contact this person for all data requests. Per the terms of the contract a response to the data request is required within 2 weeks of the request

Data Request Contact Phone Number*

Phone

Data Request Contact Extension

Data Request Contact Fax Number

Data Request Contact Email Address*

Patient Navigation Contact Name*

Take Charge! Patient Navigators will work closely with your staff person listed here.

Patient Navigation Phone Number*

Phone

Patient Navigation Extension

Patient Navigation Fax

Phone

Patient Navigation Email Address*

Contract Negotiator Name*

Take Charge! will partner with the individuals listed here on all contract negotations and contract compliance issues.

Contract Negotiator Phone Number*

Phone

Contract Negotiator Phone Number Extension

Contract Negotiator Fax Number

Phone

Contract Negotiator Email Address*

Are there any other personnel who will need access to Take Charge!, or Med-IT? Please list them here. (Leave blank if none.)

Information Provided by*

Enter the name of the person that completed this information. The date the information was entered will be automatically provided to Take Charge!.

Facility Documents Upload

Upload the facility license, insurance, Medicare/Medicaid Certification, CLIA certificate (if applicable) and subcontract if applicable.

Invoices will not be processed until current required documentation has been received.

(If these are not available now, email CancerPCP@health.ok.gov immediately to advise staff of the situation.)

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