ࡱ> { X/bjbjzz \B $PTl,($(888|U@((((((($*?-F@(]@(88(F88((r&T'8\JFn&((0(|&-!-''-.'@(@((- :  Date:  FORMTEXT       This is a request to seek the approval of Children s Behavioral Health Services, DHHS, for the agency to seek reimbursement for the Specialized Services Rate under MCBM, Section 28  RCS. Please refer to the most current version of Section 28 for specific information about Specialized Services including rate information. This request will be considered upon receipt of this fully completed form and all supporting documentation. Reimbursement under the Specialized Services rate will not be available until final approval. Please submit this request to Rachel Posner Behavioral Health Services Team Leader, Office of Child & Family Services, 2 Anthony Avenue, 11 State House Station, Augusta, Maine 04333-0011; Tel: (207) 624-7900, Fax: (207) 287-6156;  HYPERLINK "mailto:rachel.posner@maine.gov" rachel.posner@maine.gov Agency Information: Agency name:  FORMTEXT       Agency contact (address, position in agency, telephone, fax, email, TTY, cell):  FORMTEXT       Service Information Target population (age, diagnosis, range of functioning as determined by department approved tools, any other information).  FORMTEXT       Treatment (complete description of all aspects of treatment, including individual and group intervention, location(s), methods, frequency of intervention on a daily and weekly basis, expected duration, geographic areas to be served):  FORMTEXT       Please attach copies of all forms/documents that will be used to implement the treatment:  FORMTEXT       Has the agency provided the service and if so under what section(s) of the MCBM:  FORMTEXT       How will the agency ensure fidelity to a treatment model:  FORMTEXT       How will the agency address externalizing behaviors tha(*,68:<>@@ H 1 оЦoo^M<^ h 9hCJOJQJ^JaJ h 9h~KCJOJQJ^JaJ h 9hhhCJOJQJ^JaJ h 9h:CJOJQJ^JaJhu8CJOJQJ^JaJ.jh 9CJOJQJU^JaJmHnHu/jh 9hrCJOJQJU^JaJ#jh 9CJOJQJU^JaJh 9CJOJQJ^JaJ h 9hu8CJOJQJ^JaJ h 9hN(TCJOJQJ^JaJ:<>@f g 2 3 2 4 &gd 9^gd 9 & F ^gd 9^gd=e $^a$gd 9^gd 91 3 2 4  ̹ᨗsbT?)jh 9h 9CJOJQJU^JaJh 9CJOJQJ^JaJ h 9h3eCJOJQJ^JaJ#h 9h5CJOJQJ^JaJ#h 9hu85CJOJQJ^JaJ h 9hu8CJOJQJ^JaJ h 9hCJOJQJ^JaJ$h=eh=e0JCJOJQJ^JaJ)jh=eh=eCJOJQJU^JaJ h=eh=eCJOJQJ^JaJh=eCJOJQJ^JaJ " $ . 0 4 D P V f §™wfwfwfwfXF#jh 9CJOJQJU^JaJhu8CJOJQJ^JaJ h 9hCJOJQJ^JaJ h 9hu8CJOJQJ^JaJ h 9h3eCJOJQJ^JaJh 9CJOJQJ^JaJ4jh 9h 9CJOJQJU^JaJmHnHu)jh 9h 9CJOJQJU^JaJ/jth 9hrCJOJQJU^JaJ h 9h 9CJOJQJ^JaJ &6 "$8:<FHJ\սլxj\jDս՛3 h 9hY CJOJQJ^JaJ/j\h 9hrCJOJQJU^JaJhCJOJQJ^JaJh 9CJOJQJ^JaJ h 9h3eCJOJQJ^JaJ#h 9h5CJOJQJ^JaJ h 9hCJOJQJ^JaJ h 9h 9CJOJQJ^JaJ.jh 9CJOJQJU^JaJmHnHu#jh 9CJOJQJU^JaJ/jh 9hrCJOJQJU^JaJ&"JFH$&(h^&&&j''' & F L^gdPg^gd 9gdPg & F L^gd 9gd 9 & F L^gd 9\| 468BDF"$■o^͟F^/jDh 9hrCJOJQJU^JaJ h 9h 9CJOJQJ^JaJ.jh 9CJOJQJU^JaJmHnHu/jh 9hrCJOJQJU^JaJh 9CJOJQJ^JaJ#jh 9CJOJQJU^JaJhCJOJQJ^JaJ h 9hhhCJOJQJ^JaJ h 9h{PCJOJQJ^JaJ h 9hCJOJQJ^JaJ$&hj~°raOAhPgCJOJQJ^JaJ#jhPgCJOJQJU^JaJ h 9h 9CJOJQJ^JaJ.jh 9CJOJQJU^JaJmHnHu/jh 9hrCJOJQJU^JaJh 9CJOJQJ^JaJ#jh 9CJOJQJU^JaJhY CJOJQJ^JaJ h 9h{PCJOJQJ^JaJ h 9hY CJOJQJ^JaJh:CJOJQJ^JaJ~&^&`&t&v&x&&&&&&&&սկ}eսWF5 h 9hhhCJOJQJ^JaJ h 9hCJOJQJ^JaJhCJOJQJ^JaJ/jhPghrCJOJQJU^JaJhPgCJOJQJ^JaJU h 9hY CJOJQJ^JaJ h 9hPgCJOJQJ^JaJhY CJOJQJ^JaJ.jhPgCJOJQJU^JaJmHnHu#jhPgCJOJQJU^JaJ/j,hPghrCJOJQJU^JaJt may result in injury to the client or staff:  FORMTEXT       Number of children to be served during the first year by geographic location (include the basis for the number):  FORMTEXT       Number of children to be served during the second year by geographic location (include the basis for the number and any anticipated changes in subsequent years):  FORMTEXT       Describe fully how families will be involved in treatment (include hours per week and methods):  FORMTEXT       Staffing and supervision by individual (names, position, educational degrees, certifications, licenses, years of experience with this service, functions in the service delivery, any other information):  FORMTEXT       Service need (why the service is needed in the area):  FORMTEXT       Other information that may assist in considering the request and attach any additional documents:  FORMTEXT           Specialized Services Rate Request MaineCare Section 28, Rehabilitative and Community Support Services for Children with Cognitive Impairments and Functional Limitations (RCS) January 3, 2013 Form 15 Page  PAGE 1 of  NUMPAGES 2 &&&&&&&& 'f'j'l'''''''''''''''''(.(r(ͼުl^Mͼ h 9hPgCJOJQJ^JaJhCJOJQJ^JaJ.jhPgCJOJQJU^JaJmHnHu/jhPghrCJOJQJU^JaJhPgCJOJQJ^JaJ#jhPgCJOJQJU^JaJ h 9h3eCJOJQJ^JaJ h 9hhhCJOJQJ^JaJ h 9hCJOJQJ^JaJ h 9hY CJOJQJ^JaJr(((((((((()))) )<)D)F)J)L)b)d))))ͻ}o^MMMMM޻ h 9hY CJOJQJ^JaJ h 9hPgCJOJQJ^JaJh3eCJOJQJ^JaJ.jhPgCJOJQJU^JaJmHnHu/jhPghrCJOJQJU^JaJhPgCJOJQJ^JaJ#jhPgCJOJQJU^JaJ h 9hCJOJQJ^JaJ h 9h3eCJOJQJ^JaJ h 9hhhCJOJQJ^JaJ'()))))+++,>,@,-,-0-2-6-8-<->-B-D-F-H-L-gdPg & F L^gdPg)))))))**&*+++++++++++++,,,,սկ||nVսկ||E|n h 9hhhCJOJQJ^JaJ/jvhPghrCJOJQJU^JaJhPgCJOJQJ^JaJ h 9h3eCJOJQJ^JaJ h 9hY CJOJQJ^JaJ h 9hPgCJOJQJ^JaJh3eCJOJQJ^JaJ.jhPgCJOJQJU^JaJmHnHu#jhPgCJOJQJU^JaJ/jhPghrCJOJQJU^JaJ,,.,0,:,<,>,@,L,x,,------*-,-.-2-4-8-:-սկ|k]E՞=9=9=h1t;jh1t;U/jbhPghrCJOJQJU^JaJhPgCJOJQJ^JaJ h 9hhhCJOJQJ^JaJ h 9hY CJOJQJ^JaJ h 9h3eCJOJQJ^JaJ h 9hPgCJOJQJ^JaJh3eCJOJQJ^JaJ.jhPgCJOJQJU^JaJmHnHu#jhPgCJOJQJU^JaJ/jhPghrCJOJQJU^JaJ:->-@-D-F-H-J-L-N-P---- .".r.t...............÷|n|n]O]h?CJOJQJ^JaJ h?h:CJOJQJ^JaJh,CJOJQJ^JaJhACJOJQJ^JaJh 9h:5OJQJ^Jh 9h:5CJaJh:CJaJh 9h:CJaJh 9h:5CJaJh 9h:aJjh 9hAU h~Kh:CJOJQJ^JaJh:h:#h,jh1t;Uh1t;L-P---".t......sa_] !&|]^|gdnDvkdZ$$IflT000P$ 0 '4 layt 9 $$Ifa$gdv $Ifgdv ..B/D/F/H/J/L/P/R/T/V/X/gdPg !&|]^|gdnD$ !]^a$gd? 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