Behavioral Health Integration Expression of Interest Form

Behavioral Health Integration Expression of Interest Form

Point of Contact Information

Throughout the Behavioral Health Integration (BHI) process, the BHI team may need to talk to you in order to gather more information or to provide status updates. Please include all information below to reduce the risk of communication issues.

Contact Name*

Please Include First and Last Name Only

Contact Email Address*

Contact Phone #*

Phone

Which of the following groups do you represent?*

Behavioral Health Organization

Primary Care Practice

Practice Information

Please provide the following information about your practice. This ensures the BHI Team has a good understanding of your location and can better provide help throughout this process.

Practice Street Address*

Practice State*

At this time, only Ohio primary care practices are being considered for this project.

Ohio

Have you previously had a BH provider within your clinic providing integrated care?

Yes

I Don't Know

Did you hire a BH provider or partner with a BH organiaztion?

Hired

Partnered

Who did you partner with?

Number of Providers

How many providers are at your location?

Useful Information

The following information would be useful for the BHI team to begin helping you. Approximations are okay.

Please be sure to answer at least one of the following questions before leaving form:

FTE, Volume of patients, Volume Visits

Volume of Patients/Visits

FTE Primary Care Clinicians

What percentage of Medicaid-reimbursable visits (versus private insurance)?

Universal Screeners Currently Using

Select or enter value

Other Universal Screeners

What other NCH services have you used or are currently involved with?

Select or enter value

Organization Information

Please provide the following information about your organization. This ensures the BHI Team has a good understanding of your interests and can better provide help throughout this process.

BH Organization Name*

In which counties do you currently have any clinical services?

Please select all counties

Select

In which counties would you be willing to provide on-site services?

Select or enter value

Does your organization accept private insurance?

Yes

Private Insurance Companies

Select or enter value

Does your organization accept Medicaid?

Yes

Medicaid Insurances Accepted

Select or enter value

What is the scope of presenting problems typically seen by your staff?

What types of services are typically provided by your staff?

Minimum Age for Services

Select

Maximum Age for Services

Select

Have you previously partnered with a primary care practice to provide integrated care?

Yes

I Don't Know

Which primary care practice did you partner with?

Send me a copy of my responses