app.smartsheet.com
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44.218.42.214
Public Scan
URL:
https://app.smartsheet.com/b/form/7796b88f1a81401193ba364b8845a404
Submission: On November 02 via api from BE — Scanned from DE
Submission: On November 02 via api from BE — Scanned from DE
Form analysis 1 forms found in the DOM
<form>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_undefined" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0"></div>
<p data-client-id="subheading_undefined" class="css-1ey0zoe e1vg1njp2">Please use the this form to submit any changes in the services that you deliver that are related to the COVID-19 situation and how it may be impacting the behavioral health
services that you are providing. It is important for us to monitor any changes in service provision to ensure that members continue to receive Medicaid and State services with no interruptions or delays during this outbreak. Eastpointe is
here to collaborate with you as any changes may occur.</p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Provider Name" data-client-type="text" id="eGZQYAg" class="css-1e3khfm ef83ajd0"><label for="text_box_Provider Name" data-client-id="label_Provider Name" class="css-1xl1v40 ekxsfat0">Provider Name</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Provider Name" data-client-id="text_box_Provider Name" data-client-type="" name="eGZQYAg" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Provider ID" data-client-type="text" id="MkEqZ97" class="css-1e3khfm ef83ajd0"><label for="text_box_Provider ID" data-client-id="label_Provider ID" class="css-1xl1v40 ekxsfat0">Provider ID</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Provider ID" data-client-id="text_box_Provider ID" data-client-type="" name="MkEqZ97" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Date form completed" data-client-type="date" id="E5jlZGN" class="css-gbq6lm ef83ajd0"><label for="date_Date form completed" data-client-id="label_Date form completed" class="css-1xl1v40 ekxsfat0">Date form
completed</label>
<p id="description_Date_form_completed" class="css-1jo9ly9 e5k3c9p0"></p>
<div class="css-1f92r3b"><input data-client-id="date_Date form completed" id="date_Date form completed" aria-label="Date form completed" tabindex="0" name="Date form completed" maxlength="100" class="css-1dpiipj epidubd0" value=""><button
tabindex="0" type="button" aria-label="Choose" class="css-17q24xo"><span title="Choose a date" class="css-14atay6 e1yrjtds0"><svg xmlns="http://www.w3.org/2000/svg" role="img" width="16" height="16" viewBox="0 0 16 16">
<title>Calendar Icon</title>
<desc>Calendar</desc>
<g fill="none" fill-rule="evenodd">
<rect width="13" height="13" x="2" y="2" fill="#005EE0" rx="1"></rect>
<path fill="#FFF"
d="M11.648 12h-.96V8.38c-.351.328-.765.571-1.241.728v-.871c.25-.082.523-.238.817-.467.294-.229.495-.496.605-.801h.779V12zm-6.385-1.33l.93-.112c.03.237.11.418.24.543.129.125.286.188.47.188a.648.648 0 0 0 .502-.226c.135-.15.203-.353.203-.608 0-.241-.065-.433-.195-.574a.621.621 0 0 0-.475-.212c-.123 0-.27.024-.44.072l.105-.783c.26.007.458-.05.595-.17a.602.602 0 0 0 .205-.476.545.545 0 0 0-.15-.403.54.54 0 0 0-.4-.15.579.579 0 0 0-.42.17c-.117.114-.188.28-.213.5l-.885-.151c.061-.303.154-.545.279-.726.124-.182.297-.324.52-.428.221-.103.47-.155.746-.155.472 0 .85.15 1.135.45.234.247.352.525.352.835 0 .44-.24.79-.721 1.053.287.061.516.199.688.413a1.2 1.2 0 0 1 .258.776c0 .44-.16.815-.482 1.125-.32.31-.72.464-1.2.464-.453 0-.829-.13-1.127-.39a1.538 1.538 0 0 1-.52-1.025zM11 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2zM6 5a1 1 0 1 1 0-2 1 1 0 0 1 0 2z">
</path>
</g>
</svg></span></button></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Contact information" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Contact information" class="css-1ogntkt e1vg1njp1">Contact information</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Person completing the form" data-client-type="text" id="yDrd87e" class="css-1e3khfm ef83ajd0"><label for="text_box_Person completing the form" data-client-id="label_Person completing the form"
class="css-1xl1v40 ekxsfat0">Person completing the form<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Person completing the form" data-client-id="text_box_Person completing the form" data-client-type="" name="yDrd87e" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Email Address" data-client-type="text" id="Ok3zQg5" class="css-1e3khfm ef83ajd0"><label for="text_box_Email Address" data-client-id="label_Email Address" class="css-1xl1v40 ekxsfat0">Email Address<span
data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Email Address" data-client-id="text_box_Email Address" data-client-type="" name="Ok3zQg5" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Title" data-client-type="text" id="Qk63ZAY" class="css-1e3khfm ef83ajd0"><label for="text_box_Title" data-client-id="label_Title" class="css-1xl1v40 ekxsfat0">Title<span data-client-id="required_indicator"
class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Title" data-client-id="text_box_Title" data-client-type="" name="Qk63ZAY" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Phone Number for the person completing this form" data-client-type="text" id="jLKDYAD" class="css-1e3khfm ef83ajd0"><label for="text_box_Phone Number for the person completing this form"
data-client-id="label_Phone Number for the person completing this form" class="css-1xl1v40 ekxsfat0">Phone Number for the person completing this form<span data-client-id="required_indicator" class="css-skcghl ekxsfat1">*</span></label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Phone Number for the person completing this form" data-client-id="text_box_Phone Number for the person completing this form" data-client-type=""
name="jLKDYAD" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Contact Information" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Contact Information" class="css-1ogntkt e1vg1njp1">Contact Information</h2>
</div>
<p data-client-id="subheading_Contact Information" class="css-1ey0zoe e1vg1njp2">If we need to follow up on any information in this form is there anyone other than the contact above that needs to be contacted</p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Additional Contact Name" data-client-type="text" id="Z6vNzYy" class="css-1e3khfm ef83ajd0"><label for="text_box_Additional Contact Name" data-client-id="label_Additional Contact Name"
class="css-1xl1v40 ekxsfat0">Additional Contact Name</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Additional Contact Name" data-client-id="text_box_Additional Contact Name" data-client-type="" name="Z6vNzYy" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Email" data-client-type="text" id="8OAKPQo" class="css-1e3khfm ef83ajd0"><label for="text_box_Email" data-client-id="label_Email" class="css-1xl1v40 ekxsfat0">Email</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Email" data-client-id="text_box_Email" data-client-type="" name="8OAKPQo" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Contact Title" data-client-type="text" id="JkNo85b" class="css-1e3khfm ef83ajd0"><label for="text_box_Contact Title" data-client-id="label_Contact Title" class="css-1xl1v40 ekxsfat0">Contact Title</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Contact Title" data-client-id="text_box_Contact Title" data-client-type="" name="JkNo85b" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Additional Contact Email" data-client-type="text" id="1ydqJAY" class="css-1e3khfm ef83ajd0"><label for="text_box_Additional Contact Email" data-client-id="label_Additional Contact Email"
class="css-1xl1v40 ekxsfat0">Additional Contact Email</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Additional Contact Email" data-client-id="text_box_Additional Contact Email" data-client-type="" name="1ydqJAY" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Additional Contact Phone Number" data-client-type="text" id="LkMpl1d" class="css-1e3khfm ef83ajd0"><label for="text_box_Additional Contact Phone Number" data-client-id="label_Additional Contact Phone Number"
class="css-1xl1v40 ekxsfat0">Additional Contact Phone Number</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Additional Contact Phone Number" data-client-id="text_box_Additional Contact Phone Number" data-client-type="" name="LkMpl1d" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Disruption in Service" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Disruption in Service" class="css-1ogntkt e1vg1njp1">Disruption in Service</h2>
</div>
<p data-client-id="subheading_Disruption in Service" class="css-1ey0zoe e1vg1njp2">Contracted Address and Site name of the Site that needs to be temporarily relocated or closed</p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Describe the disruption in service." data-client-type="text" id="lLrNYJK" class="css-1e3khfm ef83ajd0"><label for="textarea_Describe the disruption in service."
data-client-id="label_Describe the disruption in service." class="css-1xl1v40 ekxsfat0">Describe the disruption in service.</label><textarea aria-invalid="false" tabindex="0" name="lLrNYJK" id="textarea_Describe the disruption in service."
data-client-id="textarea_Describe the disruption in service." maxlength="4000" rows="20" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Contracted Site ID that’s being effected" data-client-type="text" id="bWwzYAb" class="css-1e3khfm ef83ajd0"><label for="text_box_Contracted Site ID that’s being effected"
data-client-id="label_Contracted Site ID that’s being effected" class="css-1xl1v40 ekxsfat0">Contracted Site ID that’s being effected</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Contracted Site ID that’s being effected" data-client-id="text_box_Contracted Site ID that’s being effected" data-client-type="" name="bWwzYAb"
maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Contracted Site Name that’s being effected" data-client-type="text" id="D38jZR8" class="css-1e3khfm ef83ajd0"><label for="text_box_Contracted Site Name that’s being effected"
data-client-id="label_Contracted Site Name that’s being effected" class="css-1xl1v40 ekxsfat0">Contracted Site Name that’s being effected</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Contracted Site Name that’s being effected" data-client-id="text_box_Contracted Site Name that’s being effected" data-client-type="" name="D38jZR8"
maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Does this effect the whole site or some services?" data-client-type="text" id="OkRGZv3" class="css-1e3khfm ef83ajd0"><label for="text_box_Does this effect the whole site or some services?"
data-client-id="label_Does this effect the whole site or some services?" class="css-1xl1v40 ekxsfat0">Does this effect the whole site or some services?</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Does this effect the whole site or some services?" data-client-id="text_box_Does this effect the whole site or some services?" data-client-type=""
name="OkRGZv3" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_What services does this effect?" data-client-type="text" id="NwqR7pG" class="css-1e3khfm ef83ajd0"><label for="text_box_What services does this effect?" data-client-id="label_What services does this effect?"
class="css-1xl1v40 ekxsfat0">What services does this effect?</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_What services does this effect?" data-client-id="text_box_What services does this effect?" data-client-type="" name="NwqR7pG" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Will this Site be temporaily closed?" data-client-type="text" id="A31kwWk" class="css-1e3khfm ef83ajd0"><label for="text_box_Will this Site be temporaily closed?"
data-client-id="label_Will this Site be temporaily closed?" class="css-1xl1v40 ekxsfat0">Will this Site be temporaily closed?</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Will this Site be temporaily closed?" data-client-id="text_box_Will this Site be temporaily closed?" data-client-type="" name="A31kwWk" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Time Period of Closure" data-client-type="text" id="eGZQYA8" class="css-1e3khfm ef83ajd0"><label for="text_box_Time Period of Closure" data-client-id="label_Time Period of Closure" class="css-1xl1v40 ekxsfat0">Time
Period of Closure</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Time Period of Closure" data-client-id="text_box_Time Period of Closure" data-client-type="" name="eGZQYA8" maxlength="4000"
class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Temporary Changes to Service Delivery" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Temporary Changes to Service Delivery" class="css-1ogntkt e1vg1njp1">Temporary Changes to Service Delivery</h2>
</div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Site Address" data-client-type="text" id="mLrv19n" class="css-1e3khfm ef83ajd0"><label for="text_box_Site Address" data-client-id="label_Site Address" class="css-1xl1v40 ekxsfat0">Site Address</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Site Address" data-client-id="text_box_Site Address" data-client-type="" name="mLrv19n" maxlength="4000" class="css-1p0590h e1407lhe0" value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Phone Number" data-client-type="text" id="A380wWG" class="css-1e3khfm ef83ajd0"><label for="textarea_Phone Number" data-client-id="label_Phone Number" class="css-1xl1v40 ekxsfat0">Phone Number</label><textarea
aria-invalid="false" tabindex="0" name="A380wWG" id="textarea_Phone Number" data-client-id="textarea_Phone Number" maxlength="4000" rows="2" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Action/Strategy Plan" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Action/Strategy Plan" class="css-1ogntkt e1vg1njp1">Action/Strategy Plan</h2>
</div>
<p data-client-id="subheading_Action/Strategy Plan" class="css-1ey0zoe e1vg1njp2">Action/Strategy Plan Provide any actions and alternative strategies that you are using to minimize the impact of service disruption. How long do you estimate that
there will be a disruption to the care that members receive? Please explain any other actions that you are strategizing to meet member needs?</p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Action/Strategy Plan" data-client-type="text" id="D3b129Y" class="css-1e3khfm ef83ajd0"><label for="textarea_Action/Strategy Plan" data-client-id="label_Action/Strategy Plan"
class="css-1xl1v40 ekxsfat0">Action/Strategy Plan</label><textarea aria-invalid="false" tabindex="0" name="D3b129Y" id="textarea_Action/Strategy Plan" data-client-id="textarea_Action/Strategy Plan" maxlength="4000" rows="7"
class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Providers who have First Responder Requirements" data-client-type="heading" class="css-1e2fy0l e1vg1njp0">
<div class="css-336d07 e13qqj0j0">
<h2 data-client-id="heading_Providers who have First Responder Requirements" class="css-1ogntkt e1vg1njp1">Providers who have First Responder Requirements</h2>
</div>
<p data-client-id="subheading_Providers who have First Responder Requirements" class="css-1ey0zoe e1vg1njp2">For providers who have First Responder Requirement, please specify if there will be any disruption or impact on your ability to meet
First Responder requirements and any action plans that you have in place to meet that need?</p>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Impacts on meeting First Responder Requirements" data-client-type="text" id="X5n3JA5" class="css-1e3khfm ef83ajd0"><label for="textarea_Impacts on meeting First Responder Requirements"
data-client-id="label_Impacts on meeting First Responder Requirements" class="css-1xl1v40 ekxsfat0">Impacts on meeting First Responder Requirements</label><textarea aria-invalid="false" tabindex="0" name="X5n3JA5"
id="textarea_Impacts on meeting First Responder Requirements" data-client-id="textarea_Impacts on meeting First Responder Requirements" maxlength="4000" rows="30" class="css-1lh64kx e1407lhe1"></textarea></div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="container_Additional Comments" data-client-type="text" id="MkEqZ92" class="css-1e3khfm ef83ajd0"><label for="text_box_Additional Comments" data-client-id="label_Additional Comments" class="css-1xl1v40 ekxsfat0">Additional
Comments</label>
<div style="display: flex;"><input title="" aria-invalid="false" tabindex="0" id="text_box_Additional Comments" data-client-id="text_box_Additional Comments" data-client-type="" name="MkEqZ92" maxlength="4000" class="css-1p0590h e1407lhe0"
value=""></div>
</div>
</div>
<div class="css-1o5h39n e1tmc1mx0">
<div data-client-id="email_receipt_section">
<div data-client-id="container_email_receipt" data-client-type="divider" class="css-1e2fy0l e14sboee0">
<hr data-client-id="email_receipt" class="css-1xs1ymt e14sboee2">
</div>
<div class="css-1gl0c9l excyp8g0"><label class="css-1y93uaa excyp8g1"><input data-client-id="email_receipt_checkbox" name="EMAIL_RECEIPT_CHECKBOX" type="checkbox" class="css-1czgm8r excyp8g2" value="false"><span>Send me a copy of my
responses</span></label></div>
</div>
</div>
<div class="css-1ock8o4 e1xpzprc2"><button data-client-id="form_submit_btn" disabled="" type="submit" value="submit" class="css-oltpmt e1xpzprc0"><span>Submit</span></button></div>
<div data-client-id="footer" class="css-ybae4b e8i4qwl0">
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TEMPORARY IMPACT TO SERVICE DELIVERY Temporary Impact to Service Delivery Please use the this form to submit any changes in the services that you deliver that are related to the COVID-19 situation and how it may be impacting the behavioral health services that you are providing. It is important for us to monitor any changes in service provision to ensure that members continue to receive Medicaid and State services with no interruptions or delays during this outbreak. Eastpointe is here to collaborate with you as any changes may occur. Provider Name Provider ID Date form completed Calendar IconCalendar CONTACT INFORMATION Person completing the form* Email Address* Title* Phone Number for the person completing this form* CONTACT INFORMATION If we need to follow up on any information in this form is there anyone other than the contact above that needs to be contacted Additional Contact Name Email Contact Title Additional Contact Email Additional Contact Phone Number DISRUPTION IN SERVICE Contracted Address and Site name of the Site that needs to be temporarily relocated or closed Describe the disruption in service. Contracted Site ID that’s being effected Contracted Site Name that’s being effected Does this effect the whole site or some services? What services does this effect? Will this Site be temporaily closed? Time Period of Closure TEMPORARY CHANGES TO SERVICE DELIVERY Site Address Phone Number ACTION/STRATEGY PLAN Action/Strategy Plan Provide any actions and alternative strategies that you are using to minimize the impact of service disruption. How long do you estimate that there will be a disruption to the care that members receive? Please explain any other actions that you are strategizing to meet member needs? Action/Strategy Plan PROVIDERS WHO HAVE FIRST RESPONDER REQUIREMENTS For providers who have First Responder Requirement, please specify if there will be any disruption or impact on your ability to meet First Responder requirements and any action plans that you have in place to meet that need? Impacts on meeting First Responder Requirements Additional Comments -------------------------------------------------------------------------------- Send me a copy of my responses Submit Powered by Smartsheet Modern Logo On Light Privacy Notice|Report Abuse