New Jersey Department of Human Services (DHS)
Division of Mental Health and Addiction Services (DMHAS)
Mental Health Fee-For-Service (MH FFS) contract
Agency Administrative Information Form
FY 2020
SFY 2020 Page # 1 of 2 rev. 04/01/2019
Please type or print all information clearly, preferably in block style.
ADMINISTRATIVE INFORMATION
AGENCY NAME:
ADMINISTRATIVE ADDRESS:
CITY: STATE: ZIP: -
COUNTY: WEB PAGE:
MAIN AGENCY TELEPHONE NUMBER: ( ) -
FAX NUMBER: ( ) -
FEDERAL TAX ID #:
AGENCY EXECUTIVE DIRECTOR / CEO*:
NAME:
TITLE:
TELEPHONE NUMBER: ( ) - ext
EMAIL ADDRESS:
AGENCY CFO / LEAD FISCAL CONTACT*:
NAME:
TITLE:
TELEPHONE NUMBER: ( ) - ext
EMAIL ADDRESS:
MH FFS BILLING SUPERVISOR CONTACT*:
NAME:
TITLE:
TELEPHONE NUMBER: ( ) - ext
EMAIL ADDRESS:
*NOTE: the above three (3) contacts must be different and distinct personnel from the agency.
Please provide the following information for each contracted site. Please attach additional sheet, if necessary
.
DOH
LICENSE #
MH FFS SITE ADDRESS
MH FFS
PROGRAM TYPE
Levels Of Care, if
MEDICAID #
