Resource Connection Membership Application

Resource Connections Provider Association, Inc. 714 S Main St. Salisbury NC 28144 info@resourceconnectionsinc.info

Resource Connections Provider Association, Inc. 714 S Main St. Salisbury NC 28144 info@resourceconnectionsinc.info

Resource Connections Provider Association Inc. Application for Agency Membership All financial information reported in the application is kept confidential within the association's Executive Committee. This information is used to verify financial integrity of the applicant and to ensure a fair and accurate dues structure.

Phone

Address

Fax

Website Address

Federal Tax ID #

NPI #

Names of Owners (For Profit)

Executive Director/CEO

Email Address

example@example.com

Clinical Director

Email Address

example@example.com

Medical Director

Email Address

example@example.com

QA/QI Director

Email Address

example@example.com

Is the agency accredited or seeking accreditation? If yes, by whom? (Please include letter of accreditation)Yes

Please list your accrediting body.

What is the agency mission?

What type of services does your agency provide? Please list each service provided.

What are your referral sources? (e.g. Private, DSS, DJJ, MHDDSAS)

What is your total operating budget (revenue) or actual for services, including general administration and fundraising, but without depreciation. $_____________

What are your sources of income? Please check all that apply.

In Which counties does the agency provide services? Check all that apply.

Has anyone in your company who has an ownership, managerial or clinical role ever been sanctioned by any professional organization or government Organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country?

If Yes, please explain sanction by any professional organization or government Organization for violation of ethics, professional misconduct, unprofessional conduct, incompetence or negligence in any state or country?

Are you aware of any circumstances that may result in such an action? YesNo If yes, attach explanation

Other

Have you ever had a contract cancelled by another LME /MCO/Area Authority/County Program/Private Insurance in North Carolina or similar entity in another state? YesNo If yes, attach explanation

If yes, explain contract cancellation here

PLEASE INCLUDE THE FOLLOWING INFORMATION WITH THIS APPLICATION:

All financial information reported in the application is kept confidential within the association's Executive Committee. This information is used to verify financial integrity of the applicant and to ensure a fair and accurate dues structure.

Submit most recent annualized budget

Submit most recent annual audit, letter of financial solvency from CPA, or most recent 12 month audited financial statements.

Submit Program Descriptions. (Please include agency use of evidence based practice. This may be in the form of a brochure or similar material)

Submit copy of agency licenses

Letter/proof of accreditation or letter of intent to become nationally accredited

Electronic copy of logo

Certificate of Insurance

For Profit Agencies please list your owner(s) name, gender, race/ethnicity, title, email, and phone number. Non Profits please list board members and include their name, gender, race/ethnicity, title, email, and phone number.

Resource Connections Provider Association, Inc. 714 S Main St. Salisbury NC 28144 info@resourceconnectionsinc.info

Resource Connections Provider Association Inc

Application for Agency Membership

Thank you for your interest in becoming a member of Resource Connections Provider Association Inc. Our mission is to advance the access of whole person health care and integrated healthcare services for all people through education, advocacy, health policy and the provision of health equity. We are driven by our goal to provide the following to our members: 1. A voice for minority and disenfranchised health care providers. 2. A voice for underserved, minority, and disenfranchised health care recipients 3. Equitable opportunities for funding, technical assistance, and other resources to underserved, minority, and disenfranchised providers and service recipients across the state of North Carolina.

We know for many; times are hard and uncertain and joining a new organization may not be on your agenda. We understand! Currently, we are offering free Membership for our 2021 fiscal year. This offer ends December 30, 2021. We hope that during the free trial you will experience the benefits listed below and will understand the benefits of paid membership. Advocacy: As a member of Resource Connections your voice will be heard by law makers, regulatory boards, managed care organizations, and state healthcare regulatory agencies. Resource Connections shall maintain legislative and regulatory representation. Networking: As a member of Resource Connections, you will have the opportunity to interact with other professionals within the industry and outside the industry to exchange information and develop professional and social supports. Leadership Opportunities: As a member of Resource Connections, you will have the opportunity to become a leader. You will be able to join a committee or focus group, lead an advancement initiative, volunteer on community initiatives, and share your thoughts and ideas for change. Taking on any of these opportunities will allow you to lead our state to better health equity. Education: As a member of Resource Connections, you will be surrounded with state-of-the-art technology and innovative ways of practice. You will also be offered several free and discounted, business educational and developmental trainings. In addition, members will have access to the Resource Connections E- Newsletter. Group Purchasing Discounts: As a member of Resource Connections, you will be privy to group purchasing discounts for some of your major business purchases (i.e. insurance, services, & legal representation, etc

Please review and complete the attached application to start your free membership today!

Please electronically submit the completed form and supporting documentation to:

Resource Connections Provider Association Inc. at info@resourceconnectionsinc.info.

INDICATE WHICH MEMBERSHIP CATEGORY YOU ARE APPLYING FOR:

All financial information reported in the member application is kept confidential within the association's Executive Committee. This information is used to verify financial integrity of the applicant and to ensure a fair and accurate dues structure.

Non-profit or for-profit minority owned or operated minority agency that provides child welfare, behavioral health, physical healthcare, juvenile justice, developmental disabilities or a related services via in-patient care, community based programs and/or out-of- home care. Full membership agencies shall be accredited by one of the following national accrediting bodies: COA, EAGLE, CQL, Joint Commission, or CARF.

An agency that provides the services of a full member minority agency but is not yet nationally accredited. Associate members must become accredited within 24 months of provisional membership. Agencies applying for Associate Membership must have applied with an approved accrediting body, paid the fee and submit proof of payment with their membership application. Upon completion of the accreditation, associate members shall automatically be deemed the rights of full membership.

Non-profit or for-profit agency that does not provide child welfare, behavioral health, physical healthcare, juvenile justice, developmental disabilities or a related services via inpatient care, community-based programs and/or out-of- home care. Member affiliates shall be selected in accordance with the bylaws. Member affiliates shall be organizations and individuals whose ideas and philosophies aligns with the mission and purpose of Resource Connection.

PLEASE NOTE: A minority business is defined as a for profit company that is at least 51% owned by an individual that is African American, Asian, Hispanic, Native American or an individual who self identifies as LGBTQIA. If the company is publicly-traded, then the stock must be at least 51% minority-owned as well. A minority business may also be defined as a non-profit business that is operated by a board with at least 51% of the members are African American, Asian, Hispanic, Native American or LGBTQIA.

As part of the membership process, the signature below indicates an understanding of the rights and responsibilities of association membership. The agency agrees to support the purposes, program and mission of the Resource Connections Provider Association, Inc.

Signature of Executive Director/CEO Date of Signature:

Signature of Executive Director/CEO

Date of Signature

Agency Name