Letters of Intent (LOI) Templates
Eligible providers must submit a Letter of Intent (LOI) for each DAP Program Provider Type they wish to participate in. An LOI is required in order to participate in the program. If you intend to participate please complete the appropriate LOI template(s) below and send it to FFSrates@azahcccs.gov and ceo@healthcurrent.org by May 27, 2020. If you have questions about the DAP Program for CYE 2021 as it relates to HIE milestones or if your organization has not yet signed a Health Current Participation Agreement, please contact recruitment@healthcurrent.org.
Click on the appropriate LOI template(s) below to complete and return by May 27, 2020 deadline.
- BH Outpatient Clinics DAP HIE LOI Template
-
- Behavioral Health Outpatient Clinics, Provider Type 77
- Critical Access Hospitals Performance DAP HIE LOI Template
-
- Hospitals designated as a Critical Access Hospital (CAH) by May 27, 2020
- Hospitals Provider Type 02 Participation DAP HIE LOI Template
-
- Hospitals, Provider Type 02
- NEW to DAP
- Hospitals Provider Type 02 Performance DAP HIE LOI Template
-
- Hospitals, Provider Type 02
- Returning DAP
- IHS 638 Tribally Owned-Operated Facilities DAP HIE LOI Template
-
- Hospitals owned and/or operated by Indian Health Services (IHS) or under Tribal authority by May 27, 2020
- Integrated Clinics Participation DAP HIE LOI Template
-
- Integrated Clinics, Provider Type IC
- Other Hospitals Inpatient Facilities Participation DAP HIE LOI Template
-
- Psychiatric Hospitals, with the exception of public hospitals, Provider Type 71; Secure Residential Treatment Centers (17+ beds), Provider Type B1; Non-Secure Residential Treatment Centers (17+ beds), Provider Type B3; Subacute Facilities (1-16 Beds), Provider Type B5; Subacute Facilities (17+ beds), Provider Type B6; Rehabilitation Hospitals, Provider Type C4; Long Term Acute Care Hospitals, Provider Type C4
- New to DAP
- Other Hospitals Inpatient Facilities Performance DAP HIE LOI Template
-
- Psychiatric Hospitals, with the exception of public hospitals, Provider Type 71; Secure Residential Treatment Centers (17+ beds), Provider Type B1; Non-Secure Residential Treatment Centers (17+ beds), Provider Type B3; Subacute Facilities (1-16 Beds), Provider Type B5; Subacute Facilities (17+ beds), Provider Type B6; Rehabilitation Hospitals, Provider Type C4; Long Term Acute Care Hospitals, Provider Type C4
- Returning DAP