Number Name Purpose Form Location 2970C Disclosure and Consent to Release of Information Regarding Criminal or History For Applicants, Employees or Volunteers of DFPS Contractors and Subcontractors Release of information regarding criminal history or DFPS abuse and neglect history Form D 2971C Request for Criminal History and DFPS History Check Application for requesting criminal history and DFPS abuse or neglect history Form E 4108x Vendor Direct Deposit Authorization For vendor to receive direct deposit Form F 4109x Application for Texas Identification Number/Additional Mailing Address Application for identification number Form G PCS-102ET Contracting Entity and List of Staff, Subcontractors, and Volunteers – Must include Medicaid Number List the contracting entity, all service providers, and requested provider information on this form. Form H 9007FFS Internal Control Structure Questionnaire (ICSQ) for Fee for Service Contracts Contractor's disclosure of internal controls. Instructions included Form I 4736 Certificate of Insurance Documents the Contractor's Insurance Coverage Form J 5627 Evaluation & Treatment Experience Summary Documents the Contractor's Professional Experience Form K FORM M - BIPP Application Checklist STEP 1: Read the Evaluation & Treatment Open Enrollment for details of the terms and conditions of this contract. Focus on the sections that apply to BIPP Applicants. STEP 2: Organization of Electronic Submission of Application Applicant must organize its scanned and signed Application packet in the following order and format. Each flash drive or compact disc submission of the Application packet must include the following three (3) file folders with the respective listed documents included, and the documents must be in the following order, and numbered and labeled accordingly. Refer to Section 5,
Individual Individual Counseling - 86C $95.93 $134.11 Home Based Counseling - Individual - 88K $134.11 Family Family Counseling - 86F $79.93 $111.75 Home Based Counseling - Family - 88K $111.75 Group Group Counseling - 86E $23.52 $32.88 Court Related Services Court Testimony - 86H $91.19 Deposition - 86H $91.19 Mediation – 86H $91.19 Diagnostic Consultation Diagnostic Consultation - 81H $65.22 $91.19 Translator/Interpreter Services Service Code 98L Cost Reimbursement-Requires Contract Manager prior authorization Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED AREAS: Missed Appointments: Refer to Section 2.13.1 Travel to Underserved County: Refer to Section 2.13.3 fORM Q - Attachment A-2 –table C FEE SCHEDULE – EVALUATION AND TREATMENT SERVICES Payment is based on “unit of service." The allowable unit rate for the type of service delivered is the rate consistent with the highest credential held by the service provider. LCSW, LMFT, LPC & LSOTP – Psychosocial Assessment & Counseling Category Service - Service Code Location & Unit Rate In Office Home Based Out of Office Psychosocial Psychosocial Assessment – 86U $67.15 $93.88 $93.88
Individual Individual Counseling – 86C $67.15 $93.88 Home Based Counseling-Individual – 88K $93.88 Family Family Counseling – 86F $55.95 $78.22 Home Based Counseling-Family – 88K $78.22 Group Counseling – 86E $16.46 $23.01 Court Related Services Court Testimony – 86H Deposition – 86H Mediation – 86H $63.82 Diagnostic Consultation Diagnostic Consultation – 81H $63.82 Translator/Interpreter Services Service Code 98L Cost Reimbursement-Requires Contract Manager prior authorization Additional reimbursement for services provided in CPS DESIGNATED UNDERSERVED COUNTIES: Missed Appointments: Refer to Section 2.13.1 Travel: Refer to Section 2.13.3 fORM R - Attachment A-2 –table D Attachment A-2 –table D FEE SCHEDULE – EVALUATION AND TREATMENT SERVICES BATTERING INTERVENTION PREVENTION PROGRAM (BIPP) Payment is on “unit of service." The allowable unit rate is based on information in the Unit Rate column in the table below. The identified BIPP provider types must maintain accreditation through TDCJ-CJAD. LMSW, LCSW, LMFT & LPC or a TDCJ-CJAD funded BIPP Category Service - Service Code Location & Unit Rate In Office Out-of-Office Domestic Violence Assessment Report 1 unit = 1 assessment Domestic Violence Assessment Report – 86K $75.00 Group 1 unit = 1 hour sessions are 2 long (2 units) Orientation and Battering Intervention Prevention Program (BIPP) – 86L $16.46 (2 units = $32.92) $23.01 (2 units = $46.02) Court Related Services Testimony – 86H Deposition – 86H Mediation – 86H $63.82 Diagnostic Consultation Diagnostic Consultation – 81H $63.82