Philadelphia County Funding Request Form

Similar to the CBH process to request additional funding or rate increases, DBHIDS created a centralized mechanism for the submission of funding requests to the County. Implementing this process provides a centralized inventory of funding requests from providers, partners, etc. If/When funding becomes available, requests with all required materials are reviewed and prioritized by the Behavioral Health Division and signed off on by the Commissioner.


Submitters will use this DBHIDS County Funding Request Form to submit funding proposals and/or requests.* This form includes rate requests, new program or concept requests, program expansion or modification requests, and reinvestment requests.


For questions regarding reinvestment proposals, please contact Special Advisor for Administration and Finance: Deputy Commissioner’s Office, Ava Ashley at ava.ashley@phila.gov.


For questions regarding all other requests, please contact Amanda David at amanda.david@phila.gov.


*Submission of request does not guarantee that funding will be approved or allocated.

Request & Contact Information

Request Type*

Responsible for overall management of plan (budget, data, spending, status, etc.)

Name of person, who is a member of the Executive Managment team, who is responsible for this initiative/programming.

Select
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DBHIDS Strategic Alignment

P.A.C.E. framework: https://dbhids.box.com/s/ndoj6p227xodwzz2xtzdhwbunm8h81go


Check all that apply

Description of Request (SBAR)

A description of the problem/request

Including, if applicable, how this has been funded up until now?

Why is this funding necessary at this point?

Reinvestment Plan Information & Financials

New or Continuation
Type of Plan

Please indicate if this is a request for a new plan or a continuation of a current program In-Plan Start-Up (Under one year, typically 6mo-1yr, start-up) Non-Medical Only (Transportation, technology, etc.) Supplemental - In Lieu of (Why service is a cost-effective alternative, staffing FTEs/qualifications) Supplemental - In Addition to (When and why expected to be cost effective or why the service is appropriate but not cost effective, staffing)

E.g. If plan length is 3 years, amount should reflect total to be spent over entire 3-year period

E.g. 2023-2026

Include project planning time prior to starting (i.e., 6 months, 9 months, etc.)

MA eligible target population, population characteristics, number people served annually

Identify number of HealthChoices members in target population, describe unmet or under-met needs, what is expected to be achieved by the service and data to be collected to measure outcomes.

Reinvestment is not viable sustainment of an initiative. As such, please share your plan for sustainment of this initiative below.

Preliminary Financial Information

Are you currently receiving funding through DBHIDS?*

If applicable, otherwise write "n/a"

Is this program currently billing Medicaid?*

Amount of funding being requested from DBHIDS

Please share anything else here that might be helpful when considering your request

Please upload all supporting materials listed below. Requests will not be considered unless all materials are provided:


1. A Letter Justifying the Need

2. Certification Statement

3. Expenditure Summary

4. Personnel Invoice Schedule

5. Miscellaneous Item Detail

6. Most Recent Audited Financial Statement

7. Monitoring Plan and Expected Outcomes Worksheet

8. Reinvestment Budget Template (Reinvestment Proposals Only)

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