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Agency

Agency Tax ID #

What type of Medicaid provider is your agency? Please select all that apply. What type of Medicaid provider is your agency? Please select all that apply. Type 21 - Medical/Primary Care, Unlicensed Behavioral Health Type 84 - Mental Health (OhioMHAS Certified) Type 95 - Substance Use Disorder (OhioMHAS Certified)

Contact Name

Contact Email Address

What Services Are You Interested in from BHBS? What Services Are You Interested in from BHBS? EHR Implementation (CareLogic) CareLogic Structure Maintenance - Maintenance on a structure you are currently on/using EHR System Review - A review of your existing CareLogic system Full Service Billing Partial Service Billing Billing Consultation Managed Care Contracting - Commercial and Medicaid Provider Enrollment & Credentialing

What is Your Anticipated Timeline for Implementing Services with BHBS? (When would you like your services to begin with BHBS) What is Your Anticipated Timeline for Implementing Services with BHBS? (When would you like your services to begin with BHBS)ASAP1-2 Weeks3-4 Weeks1 Month2 Months3 MonthsUnsure

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