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Massachusetts Behavioral Health Partnership (BHP) Emergency Services Provider (ESP) RFR APPENDIX I: LETTER OF INTENT FORM Organization name: Indicate catchment area(s) for which the organization intends
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01
Begin by carefully reading the instructions provided on the Appendix I MBHP ESP form.
02
Fill in your personal information accurately, such as your name, contact details, and any other required identification information.
03
Make sure to provide your current address and indicate if it is a permanent address or a temporary one.
04
If applicable, fill in the information regarding your spouse or dependent, including their full name, social security number, and relationship to you.
05
Complete the financial section of the form, providing detailed information about your income, expenses, and any other financial resources.
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Keep a copy of the completed form for your records.
Who needs Appendix I MBHP ESP:
01
Individuals who are applying for or participating in the Massachusetts Behavioral Health Partnership (MBHP) Enhanced Services Program (ESP) may need to fill out Appendix I.
02
Applicants who require additional support or services for their mental health and substance use disorder may be asked to complete this form.
03
Those who meet the eligibility criteria for the MBHP ESP and are seeking specialized care can be required to provide the necessary information through Appendix I.
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What is appendix i mbhp esp?
Appendix I MBHP ESP is a form used to report certain financial information to the Massachusetts Behavioral Health Partnership.
Who is required to file appendix i mbhp esp?
Healthcare providers who are contracted with the Massachusetts Behavioral Health Partnership are required to file appendix I MBHP ESP.
How to fill out appendix i mbhp esp?
Appendix I MBHP ESP can be filled out by providing the requested financial information in the designated sections of the form.
What is the purpose of appendix i mbhp esp?
The purpose of appendix I MBHP ESP is to gather and report financial data to ensure compliance with contractual agreements.
What information must be reported on appendix i mbhp esp?
Information such as revenue, expenses, and other financial data related to healthcare services must be reported on appendix I MBHP ESP.
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