Writing a Cover Letter for the Non-Degreed Office Manager by izu13039


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									                SECTION XII
             (CCFA) PROVIDER


The contractor must comply fully with all administrative and other requirements
established in the contract.

A provider’s program must comply with the definition, eligibility, program
description, services, service fees and program evaluation component of the
CCFA program outlined in the CCFA standards.

Minimum Requirements for approval:

   1. Providers must complete training in Comprehensive Child and Family
      Assessment (CCFA) including both "Back to Basics" and "Advanced"
      trainings. Supervisors who are responsible for supervising family
      assessors must also attend the "Advanced" training. All family assessors
      must complete the Advanced Skills Training. Providers must maintain
      certificates of attendance on file for all who have attended training. All
      persons approved to complete assessments prior to January 1, 2005 must
      provide documentation of their attendance in an Advanced Training
   2. All provider agencies shall have an identified administration with authority
      over and responsibility for staff and service delivery of the CCFA program
      and services. The administration must ensure that its staff will follow the
      Georgia DFCS guidelines and requirements listed in the most current
      CCFA Standards and contract terms.
   3. All provider agencies will provide, show and maintain proof of general
      commercial liability of $1, 000,000.00 minimum insurance for their
      employees and their actions. All clinical staff must have professional
      liability insurance.
   4. It is required that counselors/assessors and clinicians (providing
      counseling services) for Wrap-Around have a minimum of a Master's level
      of education in Social Work, Counseling, or Psychology with an LCSW,
      LMFT, or LPC granted by the State of Georgia’s Composite Board of
      Professional Counselors, Social Workers and Marriage and Family
      Therapists and be in good standing with that authority.
      Counselors/assessors with a minimum Masters level education in social
      work or counseling who are not licensed by the Composite Board may
   complete assessments/WA (Clinical services) as long as they are under
   the clinical supervision of an LCSW, LMFT, or LPC.

NOTE: Bachelor’s level individuals may only facilitate the medical
    component of the assessment and/or accompany a child to the
    psychological appointment. A bachelor’s level individual is qualified
    to provide services under In-Home Case management Entitlement
    Code 71. Non-degreed individuals may transport a child to and from
    a psychological appointment and provide par-professional services
    under In-Home Case Management, In-Home Intensive Treatment, and
    Crisis Intervention.
5. All services must be offered without discrimination on the basis of political
    affiliation, religion, race, color, sex, mental or physical handicap, national
    origin, age or financial ability to pay.
6. A record of services must be maintained on each child served for a
    minimum of three years. The record must contain a complete account of
    services rendered for each child. The provider’s record, once completed,
    is the property of the Department, is confidential, and must be
7. In assessing families/providing servies, the provider must incorporate the
    Georgia Division of Family and Children Service’s policy, which prohibits
    corporal punishment or emotional, physical, sexual or verbal abuse.
8. The agency and/or provider shall adhere to the professional code of ethics
    regarding responsibility to clients, integrity, confidentiality, responsibility to
    colleagues, assessment instruments, research, advertising, and
    professional representation.
9. Providers must submit designated information to the Georgia State Office
    of Family Services for evaluation purposes. The information needed will
    be updated with each CCFA standards update.
10. All providers must be prepared to undergo annual audits and reviews by
    the Georgia DFCS State Office of Family Services or its designated
    representative in order to maintain provider status. These reviews may
    include, but not limited to, audits of staff qualification (Copy of Master’s
    Degree or License), random selections of reports of ensure regulations of
    time and content are met, and record keeping accuracy.
11. CCFA supervisory staff needs extensive knowledge of social work,
    counseling and mental health concepts. Supervisory staff must have a
    minimum of a Master's level of education in Social Work, Counseling, or
    Psychology with a LCSW, LMFT, or LPC granted by the State of GA
    Composite Board of Professional Counselors, Social Workers and
    Marriage and Family Therapists and be in good standing with that
12. Comprehensive Child and Family Assessment/Wrap-ARound (CCFA)
    bachelor level staff are limited to certain specific activities * and are
    required to have a minimum of a bachelor's level education in social work,
    counseling or psychology or a related field.
   13. Comprehensive Child and Family Assessment (CCFA)/Wrap-Around (WA)
       non-degree staff is limited to certain specific activities and they are
       required to have experience and knowledge in social services.

* See Section XII, D. for provider qualifications for each type of wrap-around

The following steps comprise the process for a provider applying for enrollment
as an "Approved Assessment Provider:" Refer to Appendix C for an application.
Open Enrollment for CCFA/Wrap-Around Service Providers will be accepted at a
minimum of once per year. The date will be posted on the internet at

     1. Provider inquiry - via email or regular mail.

     2. Private Provider Enrollment Application downloaded from the web.

     3. Technical assistance to private providers on any aspect of the application
        process is available upon request via email.

     4. Provider completes and mails application.

     5. Initial review of application completed by a member of the State Provider
        Review Committee within eight weeks of receipt. If the application meets
        the minimum standards, the application is prepared for presentation to
        the State Provider Review Committee. (This process may take up to eight

     6. Application package reviewed by State Provider Review Committee. The
        committee usually meets quarterly, unless the need arises to meet more

     7. If Provisional Status is considered, the provider is mailed the instructions
        for completing fingerprint screens for all staff. The provisional assignment
        is not made until the fingerprint results are on file.

     8. Contact is made to the Regional Director in an underserved area
        requesting placement of the provisional provider in a county department to
        complete two assessments.

     9. Once assignment is made, provisional approval letter sent within seven (7)
        to ten (10) working days with the county assignment information. of the
        committee's decision. The State provider Review Committee will assign a
        county to the provider for the purpose of completing the first two
        comprehensive child and family assessments.

     10. Provisional provider forwards the complete copies of the first two
         comprehensive child and family assessments (two separate families) to
         the State Provider Review Committee. The initial assessments must be
         completed and forwarded within 90 days of the provisional approval date.
11. A member of the State Provider Review Committee completes an initial
    review (within four weeks of receipt) of the assessments (to insure
    completeness) and forwards them to the DHR clinical psychologist
    consultant for clinical review. (Review may take up to six weeks.)

12. State Provider Review Committee convenes to review entire application.

13. State Provider Review Committee's Decision.

14. Contract Review Process - Once two assessments have been received
    and favorably reviewed by the State Provider Review Committee, the
    provider will receive a contract for services. (4- 6 weeks)

15. Once an executed contract is on file, the provider will receive a "Full
    Approval" letter. At that time the provider will be added to the CCFA
    Approved Provider List and at this time the provider may begin providing
    services. The CCFA Approved Provider List is updated monthly. (5-10

16. If the committee decides not to grant full approval, providers will be
    notified by letter.

17. Provider may re-apply by submitting a new application within one year of
    the denial date of the application.

18. Providers are asked to communicate via email. Applications and other
    correspondence must be mailed to the State Provider Committee.
    Information hand delivered by the provider will not be accepted.

I am submitting an enrollment application for:
      CCFA/WA (Assessment and Wrap-Around Services)
      CCFA (Assessments only)
      Wrap-Around (Wrap-Around Only)

Organizations will find it useful to review the Division’s Provider Standards that is
available at http://dfcs.dhr.georgia.gov/fostercare, click on Comprehensive Child and
Family Assessment and then the link for the Assessment Standards. Included in the
Standards are the service definitions, provider standards and applicable policies and

1. Your Name:

2. Title/Position:

3. Agency Name:

4. Agency Status: FEI# __________________ or SSN______________________
   For Profit,  Not-for-Profit, independent contractor,  non-profit agency,
   Community Service Board (CSB) or   for profit agency?

5. Address (Mailing)


6. Address (Physical Location)


7. Phone: ______________________ 8.Fax______________________________

9. Email address:
10. Web Page Address:

11.        Yes           No

12. .How long have you been doing Comprehensive Assessments


      13 (a). List all individuals who attended "Back to Basics" and "Advanced" training
      and the dates attended. Note: All Family Assessors must have a certificate on file
      for Advanced training.

      13 (b). List any additional training you or your staff received that enhances your
      ability to complete all aspects of the CCFA assessment program. List by name of
      training, dates of training, trainer and CEUs attained.

      14. List the county DFCS offices you are in interested in working as a provider?
      (add additional sheets as necessary)

______________________ ______________________ ______________________

______________________ ______________________ ______________________

15. List any special or unique capabilities of your agency. For example, you have staff
capability in translating in Spanish, sign language, etc.

16a) Are you or any member of your staff currently certified as a Georgia Medicaid
Rehabilitation Option Provider? _______Yes ______No
If yes, List names _____________________________________________________

16b) Are you or any member of your staff currently covered under a provider agreement
with a Care Management Organization (CMO)? _____ Yes _____No
If yes, List names _____________________________________________

16c) Do you or anyone on your staff have Medicaid certification in another state?
_____Yes _______NO If yes, List states and individual's name

17. Signature___________________________________ Date: ___________________

    Title:    __________________________________________

The Department of Human Resources, Division of Family and Children Services
reserves the right to verify any of the information provided in these attachments
with the appropriate credentialing body, licensing board, insurance carrier, or
criminal background check system. The Department will verify educational and
licensure credentials.

The following attachments must be included as part of the application:

    (1). Copy of current Business License(s) or other appropriate license or
    documentation (e.g. Letter of Incorporation).
    (1a) Evidence of business recorded with Georgia’s Secretary of State Office.

(2). Copy of proof of general commercial liability coverage of a minimum of $100,000.00
and professional liability insurance. You must include with this information a signed
release by your agency that gives Department of Human Resources, Division of
Family and Children Services (DHR/DFCS) permission to verify with the Insurance
Company. Liability coverage must include all staff or provide verification that all
persons whom you contract with have appropriate coverage.

 (3). Certified transcripts for all person(s) who will be completing the assessments/wrap-
around services and are not licensed. Provide a list by name, education, and license,
for each staff member or subcontractor. You must include with this information a
signed release by each individual that gives the Department of Human Resources,
Division of Family and Children Services (DHR/DFCS) permission to verify with
the specific credentialing body (e.g. university, college, licensing board, etc.) the
credentials listed.

(3a) Copy of license from the Georgia Secretary of State Office (required for all licensed
individuals in lieu of certified transcript).
(3b) Statement of experience for all persons who do not have a degree.
(3c) Curriculum Vitae for all staff which includes a continuous work history for the past
five years.

(4). Copies of a state and national fingerprint check (Georgia Crime Information Center -
GCIC and National Crime Information Center - NCIC) is required for all staff and all
subcontractors and their staff. Provisional Status will be considered with a satisfactory
criminal records check from a local law enforcement agency; however Provisional
Approval is contingent upon the receipt of satisfactory results from NCIC. If you are
considered for provisional status, instructions for submitting fingerprint cards will be
mailed to you.

(5). A copy of the current Georgia Driver’s license (must be legible) and current
automobile insurance must be provided on all individuals who will have the responsibility
of transporting children or families. Persons transporting children and families are
required to have coverage that is inclusive of terms/provisions for transporting children
and families.

(5a) A picture identification (legible) for all staff.
(6). A brief statement of all staff’s experience in assessing children and families.

(7). Attach two (2) current references (letters within the six months) from individuals or
organizations (at least one from a DFCS office) that are familiar with your work. Include
their name, address, and phone number on the agency letterhead.

(8). A list all individual(s)/agencies who make up your support network for the provision
of CCFA services. All providers must have approved Health Check Providers and
Psychologist/Psychiatrist as identified members of their support network or team. This
list should include the names, addresses, and telephone numbers of the
individual/agency and license number issued by the Georgia Secretary of State Office.

(10a) List the members of your staff and their specific roles and responsibilities in the
provision of both assessment services. Include an organizational chart reflecting the
individuals listed.

(10b) The name, title and professional credential of all supervisory staff and the names
of the individuals they are supervising.

(11) Discuss any staff turnover in the past year.

12) Malpractice Face Sheet – One submitted for each clinician.

13) Clinical Psychotherapeutic Expertise – One submitted for each clinician

14) Clinical Specialties

Note: Applications should be tabbed in accordance with the enrollment/re-
enrollment application numbers and attachments. The application should include
a cover letter and table of contents.

Once approved, providers are responsible for keeping their enrollment package
current by providing to the DFCS State Office of Child Protection, CCFA Provider
Review Committee, Two Peachtree Street, NW, Suite 18, Atlanta GA 30303
updated information on staffing, credentials, licensure, and insurance coverage
as changes occur.

Application and all attachments must be mailed to: (Applications will not be
accepted if they are faxed, hand delivered by the provider, or emailed.)

         The Department of Human Resources, DFCS
         Attention: CCFA Statewide Assessment Program
         2 Peachtree Street, NW, Suite 18-243
         Atlanta, Georgia 30303
For questions or assistance, call (404) 657-3459 or email to lbcofield@dhr.state.ga.us,
Clinician’s Name:__________________       Title______________ Discipline_________


Check the appropriate response. If you answer yes to any of the following
questions, please complete a detailed description.

   1. Have you ever been treated for alcoholism, substance abuse, or mental
      illness? ____Yes ____No

   2. Do you have any chronic illness or mental impairments that will limit your
   ability to perform the essential functions of this position? If yes, please list
   those reasons here:                        ____Yes ____ No

   3. Has your professional liability insurance ever been denied or canceled?
   ____ Yes ____No

   4. Has any hospital ever censured, restricted, suspended, or revoked your
   ____Yes ____No

   5. Have you ever surrendered your clinical privileges upon threat of censure,
   restriction, suspension, or revocation of such privileges?
   ____Yes ____No

   6. Has your membership in any professional society or association ever been
   canceled, revoked, or censured?
   ____Yes ____No

   7. To your knowledge, have any fee complaints been registered against you?
   ____ Yes ____ No

   8. Have Medicare, Medicaid, PRO, or PSRO authorities brought documented
   charges against you for alleged inappropriate fees nor quality of care issues?
   ____ Yes ____No

   9. Has any claim or suit for alleged malpractice ever been brought against
   you or are you aware of any circumstances that might lead to such a claim or
   suit?                                 ____Yes ____ No

   10. Have you ever been involved in business bankruptcy proceedings?
   ____Yes ____No
  Clinician’s Name_____________ Title______________

  11. Have you ever been convicted of a felony or involved in charges relating
  to moral or ethical turpitude?
   ____Yes ____No

  12. Have you ever been convicted or charged with fraud?
  ____ Yes ____No

  13. Are you currently using any illegal substances?
  ____Yes ____No

  A. Medical/ Professional Associations or Society memberships:

  B. List all current contracts with HMO or managed care companies:

            Name/Address of Company                              Approximate
            % of Practice


  C. Are you a paid employee or consultant for any health care plan? ______
     Yes ______ No
     If yes, please list the name of company and contact person/telephone.

  D. Other Insurance plans accepted (Please list those insurance plans which
     you accept as payment for
     services rendered.)
Clinician’s Name____________ Title__________        Discipline___________

Clinical Psychotherapeutic Expertise

   A. Treatment Modalities: Are there special treatment modalities that can
      facilitate appropriate referral and
      expedite treatment goals? ____ Yes ____ No Check at least 3 areas listed
      below for which you have had training and/or experience and how much
      training /experience you have had.

   1. Training- A minimum of 6 months supervised training.

   2. Experience- A minimum of one (1) year experience treating patients with
      this type of modality.
          ____ Adolescent Therapy ____ Family Therapy         ____ Behavior
          ____ Behavior Therapy      ____ Cognitive Therapy ____
          ____ EclectroconvulsiveTherapy(EAC)                ____ Group
Therapy                            _____Child Therapy
          ___ Psychopharmacology
Clinician’s Name______________ Title______                    Discipline______

Clinical Specialties: Please select up to six (6) areas listed below in which you
have training and experience and rate each for referral preferences (1= Most
Preferred/ 6= Least Preferred)

____ ADHD                     ____ Ethnic/Cultural Issues       _____Domestic

 ____ School Related Problems        ____ Gay/ Lesbian _______Chronic Mental

____ Alcohol/CD               ____ Forensics                ____ Sexual/Physical

____ Adol. Behav. Disorders ____ Borderline Pers. Traits          ____ Eating

____ Grief/Bereavement         ____ Step/Blended Families       ____ Physical

____ Chronic Pain              ____ Head Trauma                  ____ Stress

____ Chronic/Terminal Illness ____ Hearing Impaired       Women’s Bio/ Psych

____ Crisis/ Trauma            ____ Marital/Sep/Divorce          ____ Workplace

____ Developmental Disabilities ____ Men’s Issues                       ____

____ Other (please explain)

Briefly state your theoretical and practice orientation in the treatment of Mental
Health/Substance Abuse Problems.
       Comprehensive Child and Family Assessment/Wrap-Around



1.    Provide your full name.
2.    Provide the title of the person on line 1. or the position. For example,
      Executive Director, or Clinical Director, or Case Manager
3.    Provide the name of the organization that you are applying to be approved
      under. Provide the legal name and/or the name doing business as. For
      example, "Comprehensive Family and Health Services" doing business as
      "New Horizons" If applying as an Individual, list the full name of the
      individual, including his/her title. For example, Dr. Joe Smith, Ph.D.,
      Clinical Psychologist.
4.    Check the appropriate box regarding your organization status.
5.    Provide your official mailing address.
6.    Provide your organization location address if different from your mailing
      address. Otherwise enter "SAME”. A Post Office Address is not
      acceptable. You must list a physical address.
7.    Business telephone number.
8.    Business fax number.
9.    Business or other e-mail address where you wish to receive e-mail on any
      aspect of the application process. This e-mail address may be
      incorporated into an overall e-mail address book of approved providers.
      The purpose will be to disseminate information pertinent to providers
      doing assessments. Types of information that might be provided are
      training topics and dates, alerts to changes in standards, application and
      re-application information, and any other information of interest to all
      approved private providers.
10.   List your web page address, if applicable.
11.   Check the appropriate box. It is strongly recommended that you provide
      an e-mail address and keep it current. This is the preferred method of
      communication with all providers and will ensure you of getting critical
      information in a timely manner.
12.   List the number of months you have been doing assessments.
13.   Training (within the last calendar year)
      13 (a) Include with the list copies of attendance certificates for all
      individuals listed, if available.
      13(b) include any information on additional training that may be applicable.
      13 (a) Provide a complete list as indicated.
14.   List only those Georgia counties you would like to provide
      assessment/wrap-around services to.
15.   List any unique capabilities of your agency, including other types of
      services or programs you provide.
16.   List any staff that is enrolled in a Medicaid Provider program or CMO in
      Georgia or another state. Also, list the state.

17.   The Executive Director, President or equivalent must sign and date the re-
      application upon completion. If the application is from an individual as
      opposed to an organization, then the individual is responsible for signing
      the re-application. Please include the title and date signed.

Note: The State Provider Review Committee reserves the right to check
and verify the credentials, degrees, and/or licensing information on any
employee included as part of the application.

      The DFCS Field Area Map can be found at the following website:

The following steps comprise the process for a provider review and re-enrollment
as an "Approved Assessment Provider:" Refer to page 135 for a Re-enrollment

   1.     Provider sent letter informing them of time for review and re-

   2.     Provider re-enrollment package sent via mail.

   3.     State Provider Review Committee provides technical assistance to the
          provider on all aspects of the re-enrollment process. (Response within
          five (5) business days to any request for assistance.)

   4.     Provider completes and mails re-enrollment application.

   5.     State Provider Review Committee completes initial review of re-
          enrollment application to ensure it is complete. Review will include
          identifying issues to be included in various surveys. (Estimated time of
          four to six weeks.)

   6.     State Provider Review Committee surveys local County DFCS staff,
          purchasers, consumers and provider of assessment services. Surveys
          may also be done annually to address practice improvement issues.
          (Estimated time of four to six weeks.)

   7.     The State Provider Review Committee arranges for a time and date for
          an on-site review of the providers performance at a local County DFCS
          Office. Notifies provider in writing of the time and date.

   8.     State Provider Review Committee conducts on-site review of provider's
          performance, including random review of assessment records.
          Includes interview with the provider. (See Monitoring Review Form)

   9.     Re-enrollment application, survey results, and the results of the on-site
          reviews all evaluated by the State Provider Review Committee.

   10.    State Provider Review Committee's decision -- Provider notified of
          decision via letter.
Page 1 of 2
Provider:__________________________________               Agency       Individual

Counties served: _________________________

Review Date: __________________

Assessment/Wrap-Around Parent's Name: ______________
Child's Name: ____________________________

State Reviewer's Name:

REVIEW GUIDE QUESTIONS                                                 Yes    No    N/A
1. Was a Contract completed with the Provider?

2. Was a referral form sent to the provider?

3. Was contact made with the family within two days?

4. Did the provider meet with the Case manager?

5. Did the provider timely advise the county when unable to make
contact with the family?
6. Did the Provider agree to work according to the progress
payment schedule in the contract?
7. Did the provider cooperate with the County in obtaining criminal
records checks for RCA’s?
8. Did the provider arrange all medical and psychological
appointments timely?

9. Did the provider collect medical records when applicable?

10. Did the provider collect pertinent educational records?

11. Did the provider take the child for a health check with an
approved health check provider within 10 days of the child’s
placement in foster care?
12. Did the provider complete the MDT within 21 days of the
receipt of the referral?
13. Did the county receive a written report from the provider within
30 days of the referral?
14. Has the county provided the provider with a letter of any
15. Was the invoice for payment timely submitted?
16. Has the provider maintained updated and accurate information
in file at State Office? (new employees, fingerprint checks, etc.)
Page 2 of 2


On-Site Case Contact Summary

                      Date               Date                Date
Child's Name &
Date of Contact

Parent's Name and
Date of Contact
Name of Collateral,
Date and Type

Home Visit Contact Summary:

State Reviewer's Case Review Discussion with Case manager
Case Corrections Needed?         No           Yes    Date Due:
Case Corrections Completed:                           Date:
State Reviewers Case Review Comments:

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