entity change request form for approved applicationshbexmail.blob.core.windows.net/eap/ipas homepage...
TRANSCRIPT
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: Program Support at [email protected] orNavigator Program Support at [email protected]
05/31/16 Page 1 of 8
Tips for Faster Processing
Use IPAS ‘My Files’ to submit your change request form – https://ipas.ccgrantsandassisters.org/ Must submit page 1 signed; ensure all information in Sections A and B is accurate
In Section B, click on all applicable check boxes (☐) that correspond with your request
Only include the corresponding pages matching your selection(s) on Section B
If applicable, include supporting documentationTips: 1) scan at a resolution of 200 dpi, 2) only include pages that outline required changes and any necessary supportingdocumentation, and 3) save a copy of the submitted form for your records.
CHANGE REQUEST BACKGROUND INFORMATION
SECTION A – ENTITY INFORMATION AND AUTHORIZATION
Indicate which program your entity is affiliated with:
☐ CAC Program ☐ Navigator Program
Application Status: ☐ Approved ☐ Draft (make changes in IPAS)
☐ MMCP Program
☐ Pending (email EA Support)
Entity Name:
Phone Number:
Please note: The form must contain a signature from one of the two contacts listed on your application – authorized or primary contact, or an individual that can make executive decisions on behalf of the organization.
Contact Type: ☐ Authorized Contact ☐ Primary Contact ☐ Both Contacts Have Changed
Approved By:
Signature Date
Name (Print) Email Address
SECTION B – CHECKLIST OF SECTIONS NEEDING TO BE UPDATED OR CHANGED (only include those pages in your upload)
Check all the boxes that apply to request:
☐ 1. Entity Information (pages 2 – 3) ☐ 5. Request User Credential Information for IPAS,
CalHEERS, The Print Store, and LMS here
☐ 6. Counselor Information (page 8)
☐ 2. Location and Hours Information (pages 4 – 5)
o Link to Withdraw Counselor From Program
☐ 3. Counselor Reassignment (page 6)
☐ 4. Entity Contact Information (page 7)
SECTION C – REQUEST TO WITHDRAW FROM THE CAC PROGRAM ONLY (AUTHORIZED CONTACT SIGNATURE REQUIRED)
A CAC Entity can withdraw from the Program at any time and must complete and submit section 1 of the Withdraw Request Form.
The Entity is responsible for NOTIFYING all delegated consumers on their Counselor’s CalHEERS dashboard of the entity’s withdrawal from the program. Consumers can re-delegate their application by logging into their consumer account and selecting a new Counselor through the ‘Find Local Help’ portal on CalHEERS. Request to Withdraw entity from CAC Program, click link here.
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: Program Support at [email protected] orNavigator Program Support at [email protected]
05/31/16 Page 2 of 8
1.0 ENTITY INFORMATION up
Entity Name:
Business Legal Name:
Main Email Address:
Website Address:
Primary Phone Number (area code & ext.):
Secondary Phone Number (area code & ext.):
Fax Number (include area code)
Federal Employment Identification Number (supporting documentation required):
State Tax ID (supporting documentation required):
Category: ☐ Non-profit ☐ For-profit ☐ Governmental organization
1.1 ORGANIZATION TYPE (SUPPORTING DOCUMENTATION REQUIRED)
☐ American Indian Tribes or TribalOrganizations
☐ Licensed attorneys (e.g. family lawattorneys who have clients that areexperiencing life transitions)
☐ Licensed Health careInstitutions
☐ Chambers of Commerce ☐ Licensed health care clinics(select subcategory below)
☐ Licensed Health Care Provider
☐ City Government Agencies ☐ Federally Qualified HealthCenter (FQHC)
☐ Non-Profit CommunityOrganizations
☐ Commercial Fishing IndustryOrganizations
☐ FQHC Look-alike ☐ Ranching and FarmingOrganizations
☐ Community Colleges andUniversities
☐ Indian Health Services Clinics:Direct Services Clinics
☐ Resource Partners of the SmallBusiness Administration
☐ County Departments of PublicHealth, City HealthDepartments, or CountyDepartments that deliver HealthServices
☐ Indian Health Services Clinics:638 Contracting orCompacting Clinics
☐ School Districts
☐ Tax Preparers as defined inSection 22251(a)(1)(A) of theBusiness and Professions Code☐ Urban Indian Health Centers
☐ Faith-Based Organizations ☐ Community Clinic ☐ Trade, industry and professionalorganizations
☐ Indian Health Services Facilities ☐ Free Clinic ☐ Other public or private entitiesor individuals who meet therequirements (please specify):
☐ Labor Unions ☐ Other Clinic (please specify):
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: Program Support at [email protected] orNavigator Program Support at [email protected]
05/31/16 Page 3 of 8
1.2 SPECIAL POPULATIONS SERVED
1. Does the entity serve families of mixed immigration status? ☐ Yes ☐ No
2. Does the entity provide services to persons with disabilities? ☐ Yes ☐ No
Disability(ies) served: ☐ Hearing Impaired ☐ Visually Impaired ☐ Wheelchair Accessible
☐ Other (specify):
1.3 COUNTY(IES) SERVED BY YOUR ENTITY (CHECK ALL THAT APPLY):
☐ Alameda ☐ Marin ☐ San Mateo
☐ Alpine ☐ Mariposa ☐ Santa Barbara
☐ Amador ☐ Mendocino ☐ Santa Clara
☐ Butte ☐ Merced ☐ Santa Cruz
☐ Calaveras ☐ Modoc ☐ Shasta
☐ Colusa ☐ Mono ☐ Sierra
☐ Contra Costa ☐ Monterey ☐ Siskiyou
☐ Del Norte ☐ Napa ☐ Solano
☐ El Dorado ☐ Nevada ☐ Sonoma
☐ Fresno ☐ Orange ☐ Stanislaus
☐ Glenn ☐ Placer ☐ Sutter
☐ Humboldt ☐ Plumas ☐ Tehama
☐ Imperial ☐ Riverside ☐ Trinity
☐ Inyo ☐ Sacramento ☐ Tulare
☐ Kern ☐ San Benito ☐ Tuolumne
☐ Kings ☐ San Bernardino ☐ Ventura
☐ Lake ☐ San Diego ☐ Yolo
☐ Lassen ☐ San Francisco ☐ Yuba
☐ Los Angeles ☐ San Joaquin
☐ Madera ☐ San Luis Obispo
1.4 RESOURCE DIRECTORY
Do you want your organization listed as a resource for Counselors looking for affiliation? ☐ Yes ☐ No
1.5 GRANT FUNDING
Is the Entity a recipient of an O & E Grant from Covered California, Department of Health Care Services, Health Center Outreach and Enrollment Assistance or Connecting Kids to Coverage?
☐ Yes ☐ No
Funding program and organization granting the funds:
Grant award amount: ____________________
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: Program Support at [email protected] orNavigator Program Support at [email protected]
05/31/16 Page 4 of 8
2.0 LOCATION AND HOURS INFORMATION up
Complete section 2.0 for each site location to be updated. If adding or removing a subsite, remember to reallocate the corresponding Counselors assigned to that site (complete section 3.0 – Counselor site assignments).
Site Type (Required): ☒ Primary Site ☐ Sub-site ☐ Sub-Contractor of Navigator Lead
Action Requested: ☐ Change Site Info* (only
applicable sections required)
☐ Add site (2.0 – 2.7 Required) ☐ Remove site (2.0 Required)
Complete section 3.0 to: -Reallocate Counselor to site -Change/Update Counselor contact info on Find Local Help
Site Name: County:
Primary Contact Person for this Site:
* Does this change affect Counselor contact information displayed on Find Local Help? (If Yes, complete section 3.0)
Email Address for Consumers to Contact Site:
Primary Phone # for Consumers: (____) _____ - _______ Secondary Phone #: (____) _____ - _______
NOTE: Phone extention numbers do not appear on Find Local Help.
This site accepts consumer requests for enrollment assistance by appearing on Find Local Help? ☐ Yes ☐ No**
** If ‘No’, a consumer cannot delegate a new or renewal application to Counselors assigned to this site.
2.1 HOURS OF OPERATION
Indicate the hours of availability to provide enrollment assistance for each day of the week; each day must be filled out. ‘By Appointment Only’ is not a valid option on the CoveredCA.com (CalHEERS site).
From To
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
2.2 SITE MAILING ADDRESS
Street Address: Suite/Apt/Floor:
City: State: Zip Code:
2.3 SITE PHYSICAL ADDRESS
☐ Check this box if the physical address is the same as the mailing address.
Street Address: Suite/Apt/Floor:
City: State: Zip Code:
2.4 LANGUAGE(S) SERVICES REPRESENTED BY THE COUNSELORS AT THE SITE
Spoken Language(s) (check all that apply):
☐ Arabic ☐ English ☐ Khmer ☐ Russian ☐ Vietnamese
☐ Armenian ☐ Farsi ☐ Korean ☐ Spanish ☐ Other (specify):
☐ Cantonese ☐ Hmong ☐ Mandarin ☐ Tagalog __________________
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: Program Support at [email protected] orNavigator Program Support at [email protected]
05/31/16 Page 5 of 8
Written Language(s) (check all that apply):
☐ Arabic ☐ Farsi ☐ Korean ☐ Tagalog ☐ Other (specify):
☐ Armenian ☐ Hmong ☐ Russian ☐ Tradional Chinese Characters
☐ English ☐ Khmer ☐ Spanish ☐ Vietnamese
2.5 ESTIMATE THE NUMBER OF INDIVIDUALS SERVED FOR EACH AGE GROUP AT THIS SITE:
Under 18 years of age 35 – 44 years of age 65 years of age or older
18 – 24 years of age 45 – 54 years of age
25 – 34 years of age 55 – 64 years of age
2.6 ESTIMATE THE PERCENTAGE OF INDIVIDUALS SERVED FOR EACH ETHNICITY AT THIS SITE (MUST TOTAL 100%):
African % Chinese % Latino %
African American % Filipino % Middle Eastern %
American Indian or Alaska Native % Hmong % Russian %
Armenian % Japanese % Ukrainian %
Cambodian % Korean % Vietnamese %
Caucasian % Laotian % Other (Specify):
%
2.7 INDICATE THE EMPLOYMENT INDUSTRY(IES) OF THE POPULATION SERVED (CHECK ALL THAT APPLY):
☐ Animal production ☐ Automotive repair and maintenance
☐ Barber shops ☐ Beauty salons
☐ Car washes ☐ Child day care services
☐ Clothing stores ☐ Construction
☐ Crop production ☐ Cut and sew apparel manufacturing
☐ Department and discount stores ☐ Drinking places, alcoholic beverages
☐ Employment services ☐ Fabric mills, except knitting
☐ Gasoline stations ☐ Grocery stores
☐ Hospitals ☐ Independent artists, performing arts, spectator sports,and related industries
☐ Individual and family services ☐ Investigation and security services
☐ K-12 schools ☐ Landscaping services
☐ Amusement, gambling, and recreationindustries
☐ Personal household goods, repair, and maintenance
☐ Private households ☐ Real estate
☐ Restaurant and other food services ☐ Services to buildings and dwellings, except constructioncleaning
☐ Support activities for agriculture and forestry ☐ Taxi and limousine service
☐ Textile product mills, except carpet and rug ☐ Textile and fabric finishing, and coating mills
☐ Other ☐ Traveler accommodation
(specify):__________________________ ☐ Truck transportation
If adding or removing a site, complete section 3.0, reassign the corresponding Counselors assigned to that site.
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: Program Support at [email protected] Program Support at [email protected]
05/31/16 Page 6 of 8
3.0 COUNSELOR SITE ASSIGNMENTS AND FIND LOCAL HELP CONTACT INFO up
* Counselor Contact Info Displayed on Find Local Help. Completing this section indicates the provided email and/or phone number will display on Find Local
Help as the contact information for the listed counselor.
NOTE: CalHEERS will only reflect two sites per Counselor. If your Counselor is assigned to more than two sites, CalHEERS will not reflect the Counselor’s information on the additional site(s), preventing consumers from delegating their application to your Counselor.
COUNSELOR NAME CERTIFICATION
NUMBER REMOVE COUNSELOR FROM THIS
SITE NAME ADD COUNSELOR TO THIS
SITE NAME
*COUNSELOR CONTACT INFO DISPLAYED ON
FIND LOCAL HELP
COUNSELOR EMAIL PHONE NUMBER
Example: Jane Doe 1234567890 Corporate Office South Field Office North [email protected] (555) 555-0000
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: In-Person Assistance Support at [email protected] or Navigator Program Support at [email protected]
05/31/16 Page 7 of 8
4.0 ENTITY CONTACT INFORMATION up
If either of the Entity Contacts are also an enrollment site’s primary contact, please complete section 2.0 Location and
Hours Information pages (page 4)
Updates to Entity Contacts require the completion of section 4.3
Changes to the Primary Contact could impact the login access to multiple systems:o IPAS and/or CalHEERS: Review the User Credentials Guideo The Print Store: Indicate below in Section 4.2 or for lost/forgotten credentials review the User Credentials Guide
4.1 AUTHORIZED CONTACT (also complete section 4.3)
The Authorized Contact is the person authorized by the entity to enter into a contractual agreement with Covered California.
Name: Title:
Email Address:
Primary Phone #: (____) _____ - _______ ext. ______ Secondary Phone #: (____) _____ - _______ ext. _____
Mailing Street Mailing Suite/Apt/Floor
Mailing City: Mailing State: Mailing Zip:
4.2 PRIMARY CONTACT (changes could impact the login access to multiple systems, review the credentials guide
The Primary Contact is the person that oversees the day-to-day operations of the program.
Does this change affect the new Primary Contact’s access to supporting systems? (Yes, review the credentials guide)
Does this change affect the primary contact information for any site? (Yes, complete section 2.0.)
Name: Title:
Email Address:
Primary Phone #: (____) _____ - _______ ext. _______ Secondary Phone #: (____) _____ - _______ ext. ______
Mailing Street Mailing Suite/Apt/Floor
Mailing City: Mailing State: Mailing Zip:
NEW user credentials needed for The Print Store due to change in Primary Contact? ☐ Yes* ☐ No
* Only one user per Entity, selecting ‘Yes’ will disable access to the former user.
4.3 AUTHORIZED SIGNATURE (required if sections 4.1 and 4.2 are completed)
An authorized person is an individual who can attest that the:
New authorized contact can enter into binding contracts on behalf of the entity
Approved By:
Signature Date
Name (Print) Email Address
5.0 REQUEST USER CREDENTIALS up
Requests for user credentials must follow all instructions detailed in the Request User Credentials Guide found here.
Entities requesting login credentials for IPAS, CalHEERS, and the Print Store must complete the detailed instructions listed in Section A and Section B of the Request User Credentials Guide.
Counselors requesting login credentials for LMS and CalHEERS must follow the detailed instructions listed in Section C of the Request User Credentials Guide.
ENTITY CHANGE REQUEST FORM FOR APPROVED APPLICATIONS
Need Help? Contact: In-Person Assistance Support at [email protected] or Navigator Program Support at [email protected]
05/3116 Page 8 of 8
6.0 COUNSELOR INFORMATION up
For multiple Counselors, please insert a copy of this page for each Counselor whose information needs to be updated,
removed, or reinstated.
Check all boxes that apply:
☐ Edit Counselor ☐ Withdraw Counselor
If reinstating or reactivating a CERTIFIED counselor their CoveredCA.com username is REQUIRED to restore access.
☐ * Reinstate Counselor ☐ ** Reactivate Counselor for training (no certification number)
Counselor CoveredCA.com Login username: __________________________ (username generated when delegation code was activated)
* Counselors with an IPAS Status of ‘Denied – Failure to Renew’ require approval by Covered California to be reinstated and
must provide a brief description on why they were not able to complete the required certification training below: (REQUIRED)
** Counselors with an IPAS Status of ‘Denied – Did Not Complete Required Training’ must [email protected] to reactive their LMS account. The communication must include a statement requesting to reactive the counselor and the name of the entity.
If requesting to WITHDRAW a Counselor from the program, must complete and submit sections A and B (pg 1),and section 2 (pg 2) of the Withdraw Request Form linked here.
The Entity is responsible for notifying consumers to re-delegate their application to an alternate active counselor. Consumers can re-delegate their application by logging into their consumer account and selecting a new Counselor through the ‘Find Local Help’ portal on CoveredCA.com.
6.1 COUNSELOR INFORMATION
To update information appearing in Find Local Help (complete section 3.0)
Name (as it appears on the badge):
Legal Name: State ID/State DL #
Updating a CERTIFIED counselor’s email REQUIRES their CoveredCA.com username to update their CalHEERS user account.
Email Address: CoveredCA.com Username:
Primary Phone # (____) _____ - _______ Secondary Phone #: (___) _____ - _______
Sites served by this individual complete Section 3.0: Counselor Site Assignments (maximum of 2 sites seen on FLH)
6.2 PERSONAL MAILING ADDRESS OF THE COUNSELOR
Suite/Apt/Floor
State: Zip Code:
Street Address:
City:
6.3 LANGUAGES
Spoken Language(s) (check all that apply):
☐ Arabic ☐ English ☐ Khmer ☐ Russian ☐ Vietnamese
☐ Armenian ☐ Farsi ☐ Korean ☐ Spanish ☐ Other (specify):
☐ Cantonese ☐ Hmong ☐ Mandarin ☐ Tagalog
Written Language(s) (check all that apply):
☐ Arabic ☐ Farsi ☐ Korean ☐ Tagalog ☐ Other (specify):
☐ Armenian ☐ Hmong ☐ Russian ☐ Vietnamese
☐ English ☐ Khmer ☐ Spanish ☐ Traditional Chinese Characters