Application Request

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1) Type of Application Request:
2) Organization Physical and Mailing Address Information:
Organization Name:
Physical Address (No PO Box):
State:    City:    Zip:    +4:    County:
Mail To Copy from Physical
Mailing Address:
State:    City:    Zip:    +4:   
3) Application Request Contact Information:
Contact Name:
Phone:   Ext.  
Email:    Allow Cardinal Innovations to notify you of status changes made to your request via email.
Confirm Email:
Mail To: Copy from Physical
Mailing Address:
State:    City:    Zip:    +4:   
4) Have you ever completed a CIHS application for services in the past?
If Yes, What year?
Please explain:
   
 
 
 
 
   
5) Has this Organization ever been in business under a different name?
If Yes, what name?
6) Funding:
Do you provide Medicaid services?       Medicaid Num:
Do you provide State services?
Do you provide Outpatient Services?
Do you have a MD, DO and/or NP at your Organization?
Are you currently serving a Cardinal Innovations consumer or consumers?
(If you wish to provide further information, you may do so in the Comments section at Item 8 below. Your comments will be secure.)
7) County Identification:
Cardinal Innovations reserves the right to add or remove counties to the provider’s application based upon its capacity study and needs assessment. The provider will be contacted to discuss any additions made.
a) County of Site where this Application Request originated:
b) County where Corporate Office is located:
Remove those counties that do not apply.
c) Counties of Medicaid for Members Served:
  • Alamance
  • Cabarrus
  • Caswell
  • Chatham
  • Davidson
  • Davie
  • Forsyth
  • Franklin
  • Granville
  • Halifax
  • Mecklenburg
  • Orange
  • Person
  • Rockingham
  • Rowan
  • Stanly
  • Stokes
  • Union
  • Vance
  • Warren


d) Enter State and County if you want to Provide Services Outside of the State of North Carolina:
 
NOTE: Provider will be required to substantiate that it maintains the clinical staff to render the services at each site for which the service is selected.
Basic Inpatient and ED services (including lab codes) will automatically apply for Hospital applicants. Please identify services outside of those categories, if any, below.
Service Codes 450 and 100 will be automatically added to this Request for Application (RFA) for all Hospital applicants when you submit the RFA. Please add any additional service codes under which you intend to bill here and, if you do not intend to bill under the 450 and 100 services codes, please alert us to that fact in the Comment section below.
8) Proposed Services to Provide:
Enter a service code:
No Services Selected. Please enter a service code into the search box above, then select a provided service.
Cardinal Innovations reserves the right to add or remove the services selected for the provider’s application based upon its capacity study and needs assessment. The provider will be contacted to discuss any additions made.
 
By default, each selected service is available in all of the counties that you selected in Question 5c). If you need to exclude a county from a specific service from question 6), uncheck the county above.
9) Please identify the client population(s) served at each site as follows:
Please insert any comments you have for any of the above items. Identify the item(s) about which you are commenting for each comment made.
10) Comment:
   
  
 
 
   
Submission Information
Once you have saved your request, the Submit Request option will appear at the top of the page. Once submitted, you will be able to view your request in a view-only format while our reviewers process it.

Alamance/Caswell - Community Operations Center: (336) 513-4222
Alamance and Caswell counties

Five County - Community Operations Center: (252) 430-1330
Franklin, Granville, Halifax, Vance, and Warren counties

Mecklenburg County - Community Operations Center: (980) 938-4200

OPC - Community Operations Center: (919) 913-4053
Orange, Person, and Chatham counties

Piedmont - Community Operations Center: (704) 721-7000
Cabarrus, Davidson, Rowan, Stanly, and Union counties
Corporate Network Operations: (800) 958-5596

Application Request
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