Certified Enrollment Entity Change Request Form

Transcription

1 Certified Enrollment Entity Change Request Form USE THIS FORM TO REQUEST CHANGES, UPDATES, OR EDITS TO YOUR ONLINE CERTIFIED ENROLLMENT ENTITY APPLICATION Entity Name: Change Request Submitted For Entity ID Number: (optional) Date: Directions for Submitting Change Request Form 1) Select the sections to be changed by checking the appropriate box or boxes below 2) Complete the appropriate section(s) on pages ) Provide signature(s) as requested in designated sections 4) Upload the required documentation to your My File manager feature in IPAS: If unable to upload documents, please fax to: (559) or call (888) for assistance Required Documents: Page 1 that includes signature page and section checklist Applicable pages of identified sections changed Any required supporting documents (page 11) Tip: Only scan necessary documentation at a resolution of 200 dpi, save a copy for your records, and upload your file to My File manager feature in IPAS NOTICE: PRIMARY CONTACT S SIGNATURE REQUIRED BEFORE CHANGES WILL BE PROCESSED Changes Approved By: Signature Date Print Name Checklist of Sections Needing Changes Title SELECT THE SECTIONS TO BE CHANGED BY CHECKING THE APPROPRIATE BOX OR BOXES Entity Information Pages 2-3 Certified Enrollment Counselor Page 9 Location and Hours (Primary Site Information) Pages 4-5 Financial Information Page 10 Sub-Site Information Pages 6-7 User Information Page 10 Entity Contact Information Page 8 Required Documents for CEE/CEC Page 11 Call Covered California, Enrollment Assistance Program Help Desk at 1

2 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Entity Information WITHDRAW FROM PROGRAM (ADDITIONAL SIGNATURE REQUIRED) NOTICE: CEES WITHDRAWING FROM THE PROGRAM MUST REFER CONSUMERS TO ALTERNATIE AUTHORIZED CEES Checking this box confirms that all consumers on the CEE/CEC s dashboard have been declined and notified to reassign their application to an alternative authorized CEE/CEC Reason(s) for withdrawal: Authorized Contact Signature: Date Entity Name Business Legal Name Primary Address Fax Number (include area code) Website Address Preferred Method of Communication (select only one) Phone Fax Mail Federal Employment Identification Number State Tax ID Category (supporting documentation required in Step 7) Non-profit For-profit Governmental organization Organization Type American Indian Tribes or Tribal Organizations Licensed attorneys (e.g. family law attorneys who have clients that are experiencing life transitions) Licensed health care clinics (select a required subcategory below) Chambers of Commerce Licensed health care institutions Licensed health care provider City Government Agencies Commercial fishing industry organizations Federally Qualified Health Center (FQHC) FQHC Look-alike Non-Profit Community Organizations Ranching and farming organizations Community Colleges and Universities County departments of public health, city health departments, or county departments that deliver health services Indian Health Services Clinics: Direct Services Clinics Indian Health Services Clinics: 638 Contracting or Compacting Clinics Faith-Based Organizations Urban Indian Health Centers Indian Health Services Facilities Community Clinics Labor Unions Free Clinics Other Clinics Resource partners of the Small Business Administration School Districts Tax preparers as defined in Section 22251(a)(1)(A) of the Business and Professions Code Trade, industry and professional organizations Other public or private entities or individuals who meet the requirements (please specify): 2

3 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Entity Information (Continued) Does the entity serve families of mixed immigration status? Yes No Does the entity provide services to persons with disabilities? Yes No Disability(ies) served: Hearing Impaired isually Impaired Wheelchair Accessible Other (specify): 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 entura Lake San Diego Yolo Lassen San Francisco Yuba Los Angeles San Joaquin Madera San Luis Obispo Do you want your organization listed as a resource for Certified Enrollment Counselors looking for affiliation? Yes No Is the Entity a recipient of an Outreach and Education Grant from Covered California, Department of Health Care Services, Health Center Outreach and Enrollment Assistance or Connecting Kids to Coverage? Yes No (If yes, please provide additional information): Name of funding program and organization that granted the funding Grant Award Amount 3

4 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Location and Hours (Primary Site Information) Estimated number of individuals served annually at this site: Site Name Contact Name Primary Address County Will your organization accept referrals for consumers requesting enrollment assistance at this site? Yes No Hours of Operations Indicate the hours of availability to provide enrollment assistance for each day of the week. Each day must be filled out. Monday Tuesday Wednesday Thursday Friday Saturday Sunday From Notice: Change of Address If your CEE is compensated, please complete a new Payee Data Record (STD-204) Primary Mailing Address To Check this box if the physical address is the same as the mailing address. If it is not the same, please provide the physical address below: Primary Physical Address Indicate which language(s), both spoken and written, are represented by the Certified Enrollment Counselors at the primary site. Spoken Language(s) (check all that apply): Arabic English Khmer Russian ietnamese Armenian Farsi Korean Spanish Other (specify): Cantonese Hmong Mandarin Tagalog 4

5 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Location and Hours (Primary Site Information) (Cont.) Written Language(s) (check all that apply): Arabic Farsi Korean Tagalog Other (specify): Armenian Hmong Russian Traditional Chinese Characters English Khmer Spanish ietnamese Estimate the number of individuals served for each age group: Under 18 years of age years of age years of age years of a years of age 65 years of age or older years of age Estimate the percentage of individuals served for each ethnicity (must total 100%): African % Chinese % Latino % African American % Filipino % Middle Eastern % American Indian or Alaska Native % Hmong % Russian % Armenian % Japanese % Ukrainian % Cambodian % Korean % ietnamese % Caucasian % Laotian % Other (Specify): % Indicate the employment industry(ies) of the population served (check all that apply): Animal production Individual and family services Automotive repair and maintenance Investigation and security services Barber shops K-12 schools Beauty salons Landscaping services Car washes Amusement, gambling, and recreation industries Child day care services Personal household goods, repair, and maintenance Clothing stores Private households Construction Real estate Crop production Restaurants and other food services Cut and sew apparel manufacturing Services to buildings and dwellings, except construction cleaning Department and discount stores Support activities for agriculture and forestry Drinking places, alcoholic beverages Taxi and limousine service Employment services Textile and fabric finishing, and coating mills Fabric mills, except knitting Textile product mills, except carpet and rug Gasoline stations Traveler accommodation Grocery stores Truck transportation Hospitals Other (Specify): Independent artists, performing arts, spectator sports, and related industries 5

6 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Sub-Site Information, if applicable Complete this step for EACH sub-site location requesting be changed, edited, or updated. Make additional copies of pages 6 & 7 for each sub-site. Remove Sub-Site Add Sub-Site (remember to remove or reallocate the CEC, if any, servicing the sub-site being removed) Estimated number of individuals served annually at the sub-site: Site Name Contact Name Sub-Site Primary Address Sub-Site County Will you accept referrals for consumers requesting assistance at this site? Yes No Hours of Operations: Indicate the hours of availability to provide enrollment assistance for each day of the week. Each day must be filled out. Monday Tuesday Wednesday Thursday Friday Saturday Sunday From To Sub-site Site Mailing Address Check this box if the physical address is the same as the mailing address. If it is not the same, please provide the physical address below: Sub-site Physical Address Indicate which language(s), both spoken and written, are represented by the Certified Enrollment Counselors at the sub-site. Spoken Language(s) (check all that apply): Arabic English Khmer Russian ietnamese Armenian Farsi Korean Spanish Other (specify): Cantonese Hmong Mandarin Tagalog 6

7 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Sub-site name: Sub-Site Information (Continued) Written Language(s) (check all that apply): Arabic Farsi Korean Tagalog Other specify): Armenian Hmong Russian Traditional Chinese Characters English Khmer Spanish ietnamese Estimate the number of individuals served for each age group: Under 18 years of age years of age years of age years of a years of age 65 years of age or older years of age Estimate the percentage of individuals served for each ethnicity (must total 100%): African % Chinese % Latino % African American % Filipino % Middle Eastern % American Indian or Alaska Native % Hmong % Russian % Armenian % Japanese % Ukrainian % Cambodian % Korean % ietnamese % Caucasian % Laotian % Other (Specify): % Indicate the employment industry(ies) of the population served (check all that apply): Animal production Individual and family services Automotive repair and maintenance Investigation and security services Barber shops K-12 schools Beauty salons Landscaping services Car washes Amusement, gambling, and recreation industries Child day care services Personal household goods, repair, and maintenance Clothing stores Private households Construction Real estate Crop production Restaurants and other food services Cut and sew apparel manufacturing Services to buildings and dwellings, except construction cleaning Department and discount stores Support activities for agriculture and forestry Drinking places, alcoholic beverages Taxi and limousine service Employment services Textile and fabric finishing, and coating mills Fabric mills, except knitting Textile product mills, except carpet and rug Gasoline stations Traveler accommodation Grocery stores Truck transportation Hospitals Other (Specify): Independent artists, performing arts, spectator sports, and related industries 7

8 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Entity Contact Information Authorized Contact (Requires Signature of Authorized Personnel) The authorized contact is the person authorized by the entity to enter into a contractual agreement with Covered California. Name Address Title Mailing Street Mailing Apt/ Mailing City Mailing State Mailing Zip Preferred Method of Communication (select only one): Primary Phone Secondary Phone Mail Financial Contact (Authorized Contact s Signature Required) The financial contact is the person authorized by the applying entity to provide and handle the financial transactions between the Entity and Covered California. Name Address Title Mailing Street Mailing Apt/ Mailing City Mailing State Mailing Zip Preferred Method of Communication (select only one): Primary Phone Secondary Phone Mail Primary Contact (Authorized Contact s Signature Required) The Primary Contact provides and handles the day-to-day transactions of the Entity and transactions with Covered California. Name Address Title Mailing Street Mailing Apt/ Mailing City Mailing State Mailing Zip Preferred Method of Communication (select only one): Primary Phone Secondary Phone Mail Date of Birth: Authorized Contact Signature: Date 8

9 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Certified Enrollment Counselor(s) Complete this page for EACH Certified Enrollment Counselor the Entity is requesting be changed, edited, updated; make additional copies of page 9 for each CEC Remove CEC* Add CEC Edit CEC (*Indicate which site(s) the CEC will no longer be servicing) Changes to be included on CalHEERS website Name (This name will appear on your badge, and on CoveredCa.com through the Find Help Near You and verification portals) Legal Name California Driver s License Number or California ID number Address Preferred Method of Communication (select only one): Primary Phone Mail Is this individual Covered California Certified? Yes No If Yes, CEC Certification #: Sites served by this individual (list all that apply): Personal Mailing Address of Individual Indicate which languages the individual can speak and/or write fluently. Spoken Languages (select all that apply): Arabic English Khmer Russian ietnamese Armenian Farsi Korean Spanish Other (specify): Cantonese Hmong Mandarin Tagalog Written Languages (select all that apply): Arabic Farsi Korean Tagalog Other (specify): Armenian Hmong Russian Traditional Chinese Characters English Khmer Spanish ietnamese Educational Level (select one): Up to 8 th Grade Some High School High School Graduate Some College College Graduate Inapplicable/Not Ascertained Unknown 9

10 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Financial Information Details (Authorized Contact s Signature Required) Bank Name Bank Routing Number Account Owner Bank Account Number Account Type Checking Payment Method Check Savings Electronic Funds Transfer (EFT) Bank Address Payment Address This is the address for the Entity to receive a check from Covered California, if that option was chosen. Authorized Contact Signature: Date User Information for Approved Application NOTICE: EDITING CURRENT USER LOGIN INFORMATION REQUIRES FORMAL WRITTEN REQUEST If your Entity is approved and no longer able to access application due to: Responsible contact who generated the application left the company Username or password is lost or forgotten address to recover information is lost or forgotten All actions below are required to obtain access to an approved Entity s application in IPAS. An authorized personnel must provide a statement on company letter head expressing the following: The reason(s) for new password or login Name and of the current user First and last name of new user address and phone number of new user Title and address of new user Name and title of the authorized personnel requesting edit Address and phone number of Entity Original signature of authorized personnel Mail Letter To: Attention: Contracts Department 7625 North Palm Avenue, 107 Fresno, CA BE AWARE THAT THESE EDITS WILL RESULT IN A PHONE CALL TO THE ENTITY TO CONFIRM THE PERSONNEL REQUESTING THE CHANGES TO THE CURRENT USER IS AUTHORIZED TO MAKE SUCH AMENDMENTS. 10

11 COERED CALIFORNIA CERTIFIED ENROLLMENT ENTITY CHANGE REQUEST FORM Required Documentation Check the box associated with the document being updated, scan, and include with this submission. Check REQUIRED DOCUMENTS CERTIFIED ENROLLMENT ENTITY Certified Enrollment Entity Agreement Entities must sign and acknowledge receipt of the Certified Enrollment Entity Agreement and submit it with this form. Proof of Business Status Documentation Entities must provide proof of business status documentation that confirms the entity s status as a non-profit, for-profit, or governmental organization. Non-profits must submit proof of 501(c)3 or 501(d) determination from the IRS. All entities must provide Federal Tax Identification Number and any corresponding status determination on official letterhead. Proof of Insurance: Liability Insurance & Worker s Compensation Insurance All entities must submit a Certificate of Insurance that demonstrates that the Entity meets the following minimum insurance requirements: General liability insurance with coverage of not less than $1,000,000 per occurrence with the Exchange named as an additional insured: Covered California 560 J Street, 290 Sacramento, CA Worker s Compensation Insurance State of California-Department of Finance Payee Data Record (STD-204) All entities must submit a completed STD 204, Payee Data Record form. Proof of current or valid License and/or Certification Entities must provide documentation of the business license and other relevant certification of the Entity, including any federal or state designations. CERTIFIED ENROLLMENT COUNSELOR Mail Certified Enrollment Counselor Agreement Each individual affiliated with a Certified Enrollment Entity as a Certified Enrollment Counselor included in this form must sign the Certified Enrollment Counselor Agreement, including the Conflict of Interest Disclosure, and submit it with this form. Criminal Disclosure Every individual applying to become a Certified Enrollment Counselor must fill out a Criminal Disclosure form. This form is to be completed by the individual applying to become a Certified Enrollment Counselor and mailed to: ATTN: CEC Program Covered California P.O. Box 1199 Sacramento, CA May also be faxed to : (916) Certified Enrollment Entity personnel other than the individual applying to become Certified Enrollment Counselor may not view or collect completed forms. 11