RTC WAIVER
Community Treatment and Support for Maryland Children and Youth with Intensive Mental Health Needs
WAIVER PROVIDER APPLICATION FACE SHEET
INSTRUCTIONS: All sections must be completed. This form may be completed electronically but must be printed and
signed in the appropriate space by the director of the organization. This form should be submitted with the completed
provider application packet to the Care Management Entity (CME).
PROGRAM CONTACT INFORMATION
Name of Provider Organization or Agency (If applying as an individual, name of self):
Address Line 1:
Address Line 2:
City:
State:
Postal Code:
Telephone Number:
Fax Number:
Website:
PROGRAM DIRECTOR CONTACT INFORMATION:
Name of Program Director:
E-mail Address:
Telephone Number:
PROVIDER’S SOCIAL SECURITY NUMBER OR FEDERAL TAX ID NUMBER:
To Whom Does This Social Security Number or Tax ID Belong?
List any previous federal Tax ID numbers or Business Names:
Provider’s Current Medicaid Provider Number(s), if any:
Services for which provider is currently reimbursed by Medicaid, if any:
INDICATE ALL WAIVER SERVICE(S) THAT THE PROVIDER PROPOSES TO PROVIDE:
Caregiver Peer-to-Peer Support Services
Crisis and Stabilization Services
Expressive and Experiential Behavioral Services
Indicate which expressive & experiential behavioral service(s) the provider proposes to provide:
Art
Drama/Psychodrama
Music
Equine-Assisted
Dance/Movement
Horticultural
Family and Youth Training
In-Home Respite
Out-of-Home Respite
Youth Peer-to-Peer Support
INDICATE WHICH JURISDICTION(S) YOU ARE WILLING TO SERVE :
Allegany County
Anne Arundel County
Baltimore City
Baltimore County
Calvert County
Carroll County
Caroline County
Cecil County
Charles County
Dorchester County
Frederick County
Garrett County
Harford County
Howard County
Kent County
Montgomery County
Prince George’s County
Queen Anne’s County
Somerset County
St. Mary’s County
Talbot County
Washington County
Wicomico County
Worcester County
What additional information should families and others know about your service? What specialty populations
do you serve? (Specific age range, gender, diagnoses, languages spoken)
Page 1of 3
RTC Waiver Face Sheet—4.28.10
TO BE COMPLETED BY THE PROGRAM DIRECTOR FOR ALL RTC WAIVER SERVICES EXCEPT EXPRESSIVE &
EXPERIENTIAL BEHAVIORAL SERVICES (CHECK THE APPROPRIATE BOX FOR QUESTIONS 1 & 2):
1) Criminal History Records Check (aka background check)
I have had a complete State and FBI criminal background check completed for reasons of child care, submitted
directly to my agency, and it is available in my personnel file.
OR
At the time of this application, I have submitted my request for a complete State and FBI criminal background
check for reasons of child, along with all required fees and fingerprints, to the Department of Public Safety and
Correctional Services. The report will be issued directly to my agency. I will inform the Mental Hygiene
Administration directly as soon as the complete report is available in my personnel file.
2) Maryland Child Abuse & Neglect Clearance:
I have a Maryland child abuse and neglect clearance on-file in my agency dated within the past two years from
the date of this application that indicates that I have not been found responsible for an indicated disposition in a
child abuse or neglect investigation. As of the date of this application, I have submitted a request for a new
clearance to be sent to my agency to be maintained in my personnel file.
OR
I have never had a Maryland child abuse and neglect clearance or I had a clearance over two years ago. I have
submitted a request for a new clearance to be sent to my agency to be maintained in my personnel file. I will
inform the Mental Hygiene Administration directly as soon as the report is available in my personnel file.
TO BE COMPLETED BY EXPRESSIVE & EXPERIENTIAL BEHAVIORAL SERVICES APPLICANTS (CHECK THE
APPROPRIATE BOX FOR QUESTIONS 1 & 2):
1) Criminal History Records Check (aka background check)
I have submitted my request for a complete State and FBI criminal background check for reasons of child care,
along with all required fees and fingerprints, to the Department of Public Safety and Correctional Services, to be
issued directly to the Mental Hygiene Administration.
OR
At the time of this application, I have a complete State and FBI criminal background check completed for
reasons of child care, which was completed within the last 180 days. I have submitted a request for DPSCS to
release the findings directly to MHA, using a 180-day form.
2) Child Abuse & Neglect Clearance:
I have a child abuse and neglect clearance dated within the past two years from the date of this application
that indicates that I have not been found responsible for an indicated disposition in a child abuse or neglect
investigation. As of the date of this application, I have submitted a request for a new clearance to be sent to the
Mental Hygiene Administration.
OR
I have never had a child abuse and neglect clearance or I had a clearance over two years ago. I have submitted
a request for a new clearance to be sent to the Mental Hygiene Administration.
Page 2of 3
RTC Waiver Face Sheet—4.28.10
TO BE SIGNED BY THE PROGRAM DIRECTOR OR, IF SELF-EMPLOYED, THE INDIVIDUAL APPLICANT:
I, the undersigned, am authorized to complete this application and attest that all of the information contained
in this application packet is true and accurate to the best of my knowledge.
Printed Name:
Title:
Signature: _____________________________ Date:
For Waiver Administrative Use Only:
Date of receipt at CME:
Notes:
Date of receipt at ValueOptions:
Notes:
Proposed Specialty Code(s) for the Provider:
295—RTCW CAREGIVER PEER SUPPORT (RTCW CRGVR)
296—RTCW CRISIS & STABILIZATION (RTCW CRSIS)
297—RTCW FAMILY & YOUTH TRAINING (RTCW F&YT)
298—RTCW IN-HOME RESPITE (RTCW IRSPT)
299—RTCW OUT-OF-HOME RESPITE (RTCW ORSPT)
300—RTCW YOUTH PEER SUPPORT (RTCW YTHP)
MHA Review Date:
301—RTCW ART THERAPY (RTCW ART)
302—RTCW DANCE THERAPY (RTCW DANCE)
303—RTCW EQUINE-ASSISTED THERAPY (RTCW EQUIN)
304—RTCW HORTICULTURAL THERAPY (RTCW HORT)
305—RTCW MUSIC THERAPY (RTCW MUSIC)
306—RTCW DRAMA THERAPY (RTCW DRAMA)
Notes:
Date submitted to Maryland Medicaid:
Page 3of 3
RTC Waiver Face Sheet—4.28.10