OMB control number 0938-1295
Expiration Date: 12/31/2021

Congratulations you have successfully submitted your petition!

Background

Instructions


Petition Form

About You


Requested Action

Select Add if you wish to be newly added to the HHS ECP List, including additional provider site locations. Affiliated practitioners located at same street location will appear only once on the ECP List, so please list the facility rather than individual practitioners located at same facility, indicating the number of qualified FTE practitioners available at the facility in questions 15 and 16. Solo practitioners may submit the petition under their individual provider location.

Select Change if you are a provider that already appears on the ECP List and you wish to change/update or add missing required data (e.g., NPI, POCs, FTEs) to your facility row. If you are unsure of whether you appear on the ECP List, click the button labeled “Check to see if you are on the list” and enter your site name using the search functionality to identify your ECP Reference Number. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.

Select Remove if you wish to be removed from the HHS ECP List. If you are requesting to be removed, please enter your ECP Reference Number in question 7 from the ECP List embedded within this petition by clicking the button labeled “Check to see if you are on the list” and enter your site name using the search functionality. Note that the ECP Reference Number for each facility on the ECP list appears in column A titled “ECP Reference Number of the Excel spreadsheet, rather than referring to the electronic row number assigned by Excel.

Please note that if you return to this question to revise your selection, any data that you have entered for questions 7-46 will be deleted.
Check to see if you are on the list

Eligibility

Select Yes if you are one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian Health Care Provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding. For a complete list of organizations that are eligible for the 340B program, see http://www.hrsa.gov/opa/eligibilityandregistration/index.html. Select No if you are not one of the following types of providers: (1) eligible for or participating in the 340B program; (2) a Rural Health Clinic; (3) an Indian Health Care Provider; or (4) a State-owned family planning service site, governmental family planning service site, or not-for-profit family planning service site that does not receive Federal funding under special programs, including under Title X of the PHS Act or other 340B-qualifying funding.
For inpatient hospitals, including children’s hospitals, please indicate the number of staffed hospital beds. If the facility is not an inpatient hospital or children’s inpatient hospital, please enter 0.
For inpatient hospitals, including children’s hospitals, please enter 0. For all other ECP categories, please enter number of FTEs representing MDs, DOs, PAs and NPs authorized by the State to independently treat and prescribe medication within the listed facility at this street location, as of the date of your petition submission. Two part-time practitioners can be counted as one FTE and fractional FTEs up to two decimal places can be reported (e.g., 0.75). Multiple affiliated MDs, DOs, PAs and NPs practicing within the same provider facility located at the same street location (regardless of different suite/floor number) will appear on one row on the HHS ECP List, so please list the facility and indicate number of affiliated FTE practitioners located at the facility rather than submitting a petition for each individual practitioner. Also, practitioners who practice within a multi-practitioner facility should not submit a petition under their individual practitioner NPI independent of the facility in which they practice; rather, only individuals authorized by the facility should submit the petition using the facility-level NPI and indicate the number of affiliated FTE practitioners practicing within the facility. Multi-practitioner facilities with multiple locations should submit a petition for each site location, entering the NPI associated with each of its facility-specific site locations, and indicating the number of affiliated FTE practitioners practicing only within the facility-specific site location. In contrast, solo practitioners may submit the petition under their individual practitioner NPI. If you have only dentists (DMDs and DDSs) at this facility, please enter zero in this field.
For inpatient hospitals, including children’s hospitals, please enter 0. For all other ECP categories, please enter number of FTEs representing DMDs and DDSs practicing at your facility at this street location, as of the date of your petition submission. Two part-time practitioners can be counted as one FTE and fractional FTEs up to two decimal places can be reported (e.g., 0.75). Multiple affiliated dentists practicing within the same provider facility located at the same street location (regardless of different suite number) will appear on one row on the HHS ECP List, so please list the facility and indicate number of affiliated FTE dentists located at the facility rather than submitting a petition for each individual dentist. Also, dentists who practice within a multi-practitioner facility should not submit a petition under their individual practitioner NPI independent of the facility in which they practice; rather, only individuals authorized by the facility should submit the petition using the facility-level NPI and indicate the number of affiliated FTE dentists practicing within the facility. Multi-practitioner facilities with multiple locations should submit a petition for each site location, entering the NPI associated with each of its facility-specific site locations, and indicating the number of affiliated FTE dentists practicing only within the facility-specific site location. In contrast, solo practitioners may submit the petition under their individual practitioner NPI. If you are have only medical practitioners (MDs, DOs, PAs and NPs) at this facility, please enter zero in this field.

Provider Site Information

22. ECP Category
(Select All that Apply)
Select all categories that describe the health care services that you provide. For example, if the contracted provider is a Federally Qualified Health Center (FQHC) that is also a Ryan White HIV/AIDS provider, select both the FQHC and Ryan White Provider categories. However, if you are a dental provider and provide no non-dental medical services at your facility, please select only the “Dental Providers” ECP category or the “FQHC – Dental Services” ECP category (i.e., all of the non-dental ECP categories require the petitioner to enter the FTE counts in question 15 for medical practitioners at the respective facility and the MD, DO, NP, and PA counts would not be applicable to a dental provider). If HHS is unable to verify your provision of these services with our Federal partners, we may default your listing to the “Other ECP Providers” category until such verification can be made.
23. Which of these services, if any, do you provide to patients with opioid use disorder? (Select all that apply)

Organization Information

Point of Contact (POC) 1 Information

Point of Contact (POC) 2 Information

Provider Website URL Information

PRA Disclosure Statement:
According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a valid OMB control number. The valid OMB control number for this information collection is 0938-1295, expiration date is 12/31/2021. The time required to complete this information collection is estimated to take up to 60 minutes per response, including the time to review instructions, search existing data resources, gather the data needed, and complete and review the information collection. This estimate does not include time for training. If you have comments concerning the accuracy of the time estimate(s) or suggestions for improving this form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.