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RHP 1 Participation Certifications
Section VI. RHP 1 Participation Certifications Each RHP participant that will be providing State match or receiving pool payments must sign the following certification. By my signature below, I certify the following facts: I am legally authorized to sign this document on behalf of my organization; I have read and understand this document; The statements on this form regarding my organization are true, correct, and complete to the best of my knowledge and belief. Organization Name Signature Anchor University of Texas Health Center at Tyler Received – see attached Performing Provider Anderson Cherokee Community MHMR Center (ACCESS) Andrews Center Burke Center East Texas Medical Center East Texas Medical Center Athens East Texas Medical Center Carthage East Texas Medical Center Fairfield dba ETMC Fairfield East Texas Medical Center Henderson East Texas Medical Center Pittsburg East Texas Medical Center Trinity East Texas Medical Center, Jacksonville ETMC Quitman Fannin County Hospital Authority dba Red River Regional Hopkins Co Memorial Hospital Hunt Mem Hosp Dist dba Hunt Reg Med Ctr Greenville Lakes Regional MHMR Center MHMR SVCS of Texoma Mother Frances Hospital Regional Healthcare Center Northeast Texas Public Health District Paris Lamar County Health Department Sabine Valley Reg MHMR Ctr dba Community Healthcore The Good Shepherd Hospital dba Good Shepherd Medical Center Titus County Memorial Hospital dba Titus Regional University of Texas Health Center at Tyler Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Organization Name IGT Entities Anderson Cherokee Community MHMR Center (ACCESS) Andrews Center Atlanta Hospital Authority Bowie County Burke Center Camp County Cass County City of Wylie Department of State Health Services Fairfield Hospital District Fannin County Hospital Authority dba Red River Regional Hospital Gregg County Harrison County Henderson County Hospital Authority Hopkins County Hospital District Hunt Memorial Hospital District Lakes Regional MHMR Center Lamar County MHMR Services of Texoma Northeast Texas Public Health District Panola County Paris Lamar County Health Department Sabine Valley Regional MHMR Center dba Community Healthcore Titus County Hospital District Town of St Paul Trinity Memorial Hospital District University of Texas Health Center at Tyler Wood County Central Hospital District UC Only Providers Atlanta Memorial Hospital Brim Healthcare of Texas, LLC dba Wadley Regional Medical Center CHRISTUS St. Michael Health System Good Shepherd Medical Center Marshall Hunt Regional Community Hospital Longview Regional Medical Center Mother Frances Hospital Jacksonville Mother Frances Hospital Winnsboro Paris Regional Medical Center Rusk State Hospital The University of Texas Health Science Center at Tyler – Hospital Signature Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see Rusk State Hospital Received – see attached Received – see attached Received – see attached Pending Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see Atlanta Hospital Authority Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached Received – see attached RHP 1 Plan May 2015 3 RHP 1 Plan May 2015 4 RHP 1 Plan May 2015 5 RHP 1 Plan May 2015 6 RHP 1 Plan May 2015 7 RHP 1 Plan May 2015 8 RHP 1 Plan May 2015 9 RHP 1 Plan May 2015 10 RHP 1 Plan May 2015 11 RHP 1 Plan May 2015 12 Section VI. RHP 1 Participation Certifications Each RHP participant that will be providing State match or receiving pool payments must sign the following certification. By my signature below, I certify the following facts: • I am legally authorized to sign this document on behalf of my organization; • I have read and understand this document; • The statements on this form regarding my organization are true, correct, and complete to the best of my knowledge and belief. Organization Name Name (Please Print) Signature Performing Provider Sabine Valley Regional MHMR Center dba Community Healthcore Inman White IGT Entity Sabine Valley Regional MHMR Center dba Community Inman White Healthcore RHP 1 Plan May 2015 13 RHP 1 Plan May 2015 14 RHP 1 Plan May 2015 15 RHP 1 Plan May 2015 16 RHP 1 Plan May 2015 17 RHP 1 Plan May 2015 18 RHP 1 Plan May 2015 19 RHP 1 Plan May 2015 20 RHP 1 Plan May 2015 21 RHP 1 Plan May 2015 22 RHP 1 Plan May 2015 23 RHP 1 Plan May 2015 24 RHP 1 Plan May 2015 25 RHP 1 Plan May 2015 26 RHP 1 Plan May 2015 27 RHP 1 Plan May 2015 28 RHP 1 Plan May 2015 29 RHP 1 Plan May 2015 30 RHP 1 Plan May 2015 31 RHP 1 Plan May 2015 32 RHP 1 Plan May 2015 33 RHP 1 Plan May 2015 34 Section VI. RHP 1 Participation Certifications Each RHP participant that will be providing State match or receiving pool payments must sign the following certification. By my signature below, I certify the following facts: x I am legally authorized to sign this document on behalf of my organization; x I have read and understand this document; x The statements on this form regarding my organization are true, correct, and complete to the best of my knowledge and belief. Organization Name MHMR Services of Texoma Name (Please Print) Performing Provider Signature 5IPNQTPO%BOJFM IGT Entity MHMR Services of Texoma RHP 1 Plan 5IPNQTPO%BOJFM May 2015 35 RHP 1 Plan May 2015 36 RHP 1 Plan May 2015 37 RHP 1 Plan May 2015 38 Section VI. RHP 1 Participation Certifications Each RHP participant that will be providing State match or receiving pool payments must sign the following certification. By my signature below, I certify the following facts: • I am legally authorized to sign this document on behalf of my organization; • I have read and understand this document*; • The statements on this form regarding my organization are true, correct, and complete to the best of my knowledge and belief. - --- - - - - ·- Organization Name _ _ ~ - - - Name . - --- - . - - - Signature (Please Print) IGT Entity Town of St. Paul Robert a. London, Town Secretary *The RHP Participation Certification is section VI of the RHP Plan, and is completed by Performing Providers, IGT Entities, UC-only hospitals and the Anchor. The person who is eligible to sign this section is certifying that 1) they are legally authorized to sign the document [RHP plan] on behalf of their organization; 2) they have read and understand the document; and 3) the statements in the RHP Plan regarding their organization are true, correct and complete to the best of their knowledge and belief. Each RHP Plan contains the following elements: RHP Organization, Executive Overview, Community Needs Assessment, Stakeholder Engagement, DSRIP Projects (includes CQI, project valuation, Category 1 and 2, Category 3, Category 4), RHP Participation Certifications, and Addendums. Because so many changes have been made to RHP Plans since they were originally submitted in 2012 (additions of QPI metrics, changes to milestones and metrics, changes to project narratives, the addition of 3-year projects, etc.L each RHP Plan has been updated according to a process outlined by HHSC and these updated plans are required to be certified in the same way the original plan submissions were certified by RHP participants. RHP 1 Plan May 2015 39 RHP 1 Plan May 2015 40 RHP 1 Plan May 2015 41 RHP 1 Plan May 2015 42 RHP 1 Plan May 2015 43