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Eligibility Attestation Form

The CalAIM PATH Technical Assistance Marketplace provides resources for organizations seeking to enhance their capacity for Enhanced Care Management and Community Supports services for Medi-Cal members. To be eligible for assistance, organizations must be contracted with or planning to contract with a Managed Care Plan or other eligible entity. An Attestation Form must be signed and submitted as part of the application process.

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30 views3 pages

Eligibility Attestation Form

The CalAIM PATH Technical Assistance Marketplace provides resources for organizations seeking to enhance their capacity for Enhanced Care Management and Community Supports services for Medi-Cal members. To be eligible for assistance, organizations must be contracted with or planning to contract with a Managed Care Plan or other eligible entity. An Attestation Form must be signed and submitted as part of the application process.

Uploaded by

Gabriela Pech
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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CalAIM Providing Access and Transforming Health

Technical Assistance Marketplace


TA Marketplace Applicant Eligibility Attestation Form
Updated: 10/16/23

PLANNING TO CONTRACT:
Organizations Planning to Contract with a Managed Care Plan (MCP) or Other Entity to
Provide Enhanced Care Management (ECM) and/or
Community Supports Services or Actively Exploring the Possibility of Contracting with
an MCP

The Providing Access and Transforming Health (PATH) Technical Assistance (TA) Marketplace makes it possible
for providers, community-based organizations, local governmental entities, such as city and county agencies,
Medi-Cal Tribal Designees and Indian Health Programs and others to access TA resources to help strengthen
their capacity to provide high quality Enhanced Care Management (ECM) and Community Supports services for
Medi-Cal members.

To be eligible to receive TA through the CalAIM PATH TA Marketplace, an applicant organization must meet one
of the eligibility options identified below:
• Contracted with a Managed Care Plan (MCP) or other entity to provide ECM/Community Support
services
• Planning to Contract with an MCP or other entity to provide ECM/Community Support services or
actively exploring that possibility with an MCP or other entity
• Approved by DHCS to receive TA

A signed Attestation Form must be uploaded to your organization’s TA Recipient Eligibility Application to
complete the application.

Organizations that meet the “Planning to Contract” eligibility criteria must also provide a signed MCP
attestation form. Please attest to your eligibility by signing below and by obtaining the signature of the MCP
or other eligible entity with which your organization is engaged.
PLANNING TO CONTRACT. By signing this form, the applicant organization attests that it is eligible to receive
TA through the CalAIM PATH TA Marketplace through the following option:

The applicant organization intends to contract with an MCP (or other eligible entity) to provide ECM/Community
Supports services or is actively exploring the possibility of contracting with an MCP (or other eligible entity) to
provide ECM/Community Supports services.

Applicant Organization
Name: ___________________________________________________________________
Contact Person and Title: ____________________________________________________
Contact Person Email: ______________________________ Phone: __________________
MCP (or other eligible entity) to be contracted with: ______________________________
Signature from Applicant Organization: _________________________________________
Printed Name: _____________________________________________________________
Date: ____________
Supplemental MCP Attestation Form

By signing this form, the MCP or other eligible entity attests that the Applicant organization is eligible to
receive TA through the CalAIM PATH TA Marketplace:

The MCP (or other eligible entity) intends to contract with the designated applicant organization to provide
ECM/Community Supports services or is actively exploring the possibility of contracting with the designated
applicant organization to provide ECM/Community Supports service.

Applicant Organization
Name: ___________________________________________________________________

MCP (or Other Eligible Entity)


Name: ______________________________________________ _
Type of Entity: ____________________________________________________________
Contact Person and Title: _________________________________________________ __
Contact Person Email: _____________________________ Phone: ________________ __
Applicant Organization to be contracted with: __________________________________
Signature from MCP (or other eligible entity): __________________________________
Printed Name: ____________________________________________________________
Date: ____________

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