An application for ECP designation shall be made on forms provided by the commissioner. The applicant shall provide all of the information described in items A to G.
The name of the applicant's contact person and that person's address and telephone number.
The applicant's status as either:
a local government unit, an Indian tribal government, the Indian Health Service, a service unit or facility, or a community health board; or
evidence of Minnesota Statutes, chapter 317A, nonprofit status, Internal Revenue Code, section 501(c)(3), tax exempt status, a copy of the applicant's current sliding fee schedule, and evidence that the applicant does not restrict access or services because of the client's financial limitation.
A list of medical services provided, by Current Procedural Terminology 95 (CPT 95) codes or categories of Current Procedural Terminology 95 (CPT 95) codes.
Evidence of the applicant's capacity to provide medical services in a timely manner consistent with community norms, including the number and type of health professionals available and the applicant's appointment scheduling guidelines and procedures.
A list of which of the following populations the applicant serves: uninsured persons, high risk and special needs populations, and underserved and other special needs populations. In addition, the applicant must provide:
the total number of clients falling within the populations served annually; and
what percent of the applicant's total patient population falls within those populations.
A list of supportive and stabilizing services available including an explanation of how the need for services is assessed, how clients access the services, how these services are made available to clients in need of such services, and to what extent these services are used by clients. If specific supportive and stabilizing services are not available, an explanation of why the following services are unavailable or inappropriate for the specific populations served by the applicant:
culturally sensitive and competent services; and
other supportive and stabilizing services.
Any other information requested by the commissioner that is reasonably necessary to determine whether the application should be granted or denied.
MS s 62Q.19
21 SR 6
September 26, 1997