Grant Attestation

    III. PROVIDER PROFILE QUESTIONS

    PLEASE ATTACH A DETAILED EXPLANATION FOR ANY QUESTIONS BELOW THAT WERE ANSWERED “YES.”

    A. Please answer the following questions regarding your organization’s programs:

    1. Has the organization, or any other Provider Entity, had its professional liability or malpractice insurance refused, revoked, declined, or accepted on special terms in the past five (5) years?

    2. Has any government agency suspended, revoked, or taken other action against the organization’s license in the past five years?

    3. Have any accreditations or memberships been revoked, reduced, denied, or suspended in the past five years, or are any actions now underway?

    4. Has any Owner, Managing Employee, officer, or shareholder of the organization ever been convicted of a crime?

    5. Has the organization ever been denied acceptance into or withdrawn from GA DBHDD or GA Collaborative ASO network participation?

    6. Has the organization had any settled claims or judgments relating to sexual misconduct or civil rights violations in the past five years?

    7. Has the organization had any settled claims or judgments relating to any other matter not disclosed above?

    8. Has the organization been a defendant in five (5) or more lawsuits in the past five (5) years?

    9. Does the organization employ or contract with individuals listed on the Office of Inspector General’s List of Excluded Individuals/Entities?

    10. Has the organization filed for Bankruptcy in the past five years?

    CARELINK OF GEORGIA OPIOID TREATMENT PROVIDERS OF GEORGIA GRANT ATTESTATION

    Attestation for Opioid Treatment Providers (OTPG)


    By executing this attestation, the undersigned verifies the following with respect to its application to participate in the Opioid Treatment Providers (OTPG), Department of Behavioral Health & Developmental Disabilities (DBHDD) Grant.

    Agreement and Compliance


    I hereby attest that my staff, agents, contractors, subcontractors, billing agents, and I have reviewed and agree to comply with the terms and conditions set forth in the applicable DBHDD and Department of Community Health (DCH) Provider Manuals.

    Program Agreement


    My program agrees to provide Medication for Opioid Use Disorder (MOUD) Treatment Services to individuals who meet the admission and continued stay criteria in accordance with The Department of Behavioral Health & Developmental Disabilities (DBHDD) Provider manual definition of Medication Assisted Treatment located at:
    Provider Manual.

    Policy Updates


    I understand and acknowledge that the policies and procedures manuals are amended (generally on a quarterly basis) when either Department finds it necessary or appropriate to do so, and that it is my responsibility to check periodically for any revisions pertaining to the delivery of or reimbursement for services rendered to eligible individuals.

    Consequences of Non-Compliance


    I further understand that failure to abide by either DBHDD or DCH policies and procedures will result in adverse consequences including, but not limited to the denial of payment, termination of contract, and reduction of reimbursement.

    Accuracy and Responsibility


    I certify and attest that I have reviewed the entire contents of the completed application and that the information provided is accurate and complete. I understand that inaccurate, incomplete or omitted data may lead to adverse consequences including, but not limited to the denial of payment, termination of contract, and reduction of reimbursement.

    Program Data Sharing


    I attest that my program will share patient program data as requested by CareLink or DBHDD. I certify and attest that my program is not currently a recipient of grant funding from any other DBHDD grant for MOUD treatment services.

    Declaration


    I hereby declare under penalty of perjury that the foregoing is true and correct. I do hereby affirm that I am the authorized agent to complete this document, and that information contained herein this document is complete, true, and correct to the best of my knowledge. I understand that material misrepresentation and/or falsification of any information contained herein shall result in the immediate removal of further consideration for participation.

    Executed on ___________, _____, 202__ in ___________ (city), ________ (state).

    __________________________________
    Signature of Authorized Officer or Agent

    __________________________________
    Printed Name and Title of Authorized Officer or Agent

    SUBSCRIBED AND SWORN BEFORE ME
    ON THIS THE ______ DAY OF ______________, 201__.
    _______________________________________________
    NOTARY PUBLIC
    My Commission Expires: __________________________