ࡱ> #` ĭbjbj\.\. 4>D>D0FFFFFFF |W|W|W8WXX0 hY[4(\(\(\]]d ^4giiiiii$̫h4VF(a]](a(aFF(\(\zDdDdDd(aF(\F(\gDd(agDdDdFF;(\\Y 0YIN|W8a8C$0PTap;F;?^^^Dd!_Lm_?^?^?^4d?^?^?^(a(a(a(a00($Ad00(AZtJFFFFFF 2007 Application for Health Information Technology Funding Application Process The Washington Health Information Collaborative (Collaborative) must receive Application for funding by close of business, 5:00 PM PDT August 15, 2007. Application may be submitted via e-mail to  HYPERLINK "mailto:Thecollaborative@fchn.com" Thecollaborative@fchn.com, (Subject: Collaborative Application). If submitting via e-mail, applicant may include a scan of the signed Statement of Assurances (PDF or JPEG file). Applicant may also deliver the application as an original document to: First Choice Health ATTN: The Collaborative 600 University Street, Suite 1400 Seattle, WA 98101. Applicant should not submit Application as a faxed document. Applicant may choose to follow up an e-mailed application with a faxed copy of the Statement of Assurances if unable to convert that document to electronic format. Please send faxes to (206) 268-2882, attn: The Collaborative. Please be aware, it is Applicants responsibility to ensure the timely receipt of your entire Application by the Collaborative. Failure to submit complete Application by the specified deadline will disqualify Applicant from further consideration in this award cycle. Applicant is encouraged to review the document Determining If Your Practice is Ready to Adopt Health IT for guidance on what elements should be reflected in your strategic, funding, project plans and your budget. The document can be found here:  HYPERLINK "http://www.wahealthinfocollaborative.org/#How" www.wahealthinfocollaborative.org/#How Important information Applicant refers to the organization on whose behalf Application is submitted. Application refers to a submission of a request for funding, including all attachments thereto, in response to the 2007 Announcement of Health Information Technology Funding Opportunity (Announcement). Funding for direct costs only of up to $20,000 for projects of up to 18 months in duration may be requested. The anticipated number of awards is not known. Awards issued by the Collaborative under the Announcement are contingent upon availability of funds and submission of a sufficient number of meritorious applications. Because the nature, scope and duration of proposed projects will vary from application to application, it is anticipated that the size of each award will also vary. The total amount awarded and the number of awards will depend upon the quality and costs of the applications received. Applications will be evaluated by scoring across multiple dimensions including: Planning; IT Selection; Budget; Implementation and Grant Goals. Decision to fund Application will be based on whether Applicant meets eligibility criteria, on available funds, and on Application scoring. By submitting an Application, Applicant recognizes that a decision not to award or to award funds at a particular funding level to Applicant is discretionary and is not subject to appeal. The signature of an authorized individual on Statement of Assurances certifies that Applicant will comply with all applicable rules of the application process and all assurances contained in the Statement of Assurances. Applicants for and recipients of award funds are responsible for complying with and must adhere to all applicable Federal and State statutes, codes, regulations, and policies including income tax regulations. Questions relating to the applicability of income tax regulations to awarded funds should be directed to the IRS. Funding to successful applicants will be provided by either First Choice Health (First Choice) or the Health Care Authority (HCA). HCA funding is contingent upon receipt of funding under the parameters of Section 1621 of SHB 1128. Application allows Applicant to request funds from First Choice, the HCA or both entities. Checking both boxes will not increase the possible funds to be received but will ensure that both organizations will review your application. Please refer to the eligibility criteria outlined on page four the Announcement to determine if you are eligible for funding from either source. Please remember that all applications submitted for review to the HCA are subject to applicable public disclosure laws. Selection process Applicants must meet the eligibility criteria outlined on page four of the Announcement. If review of the Application shows your organization does not meet these criteria, the Application will be disqualified from further consideration To be considered for review, the Application must also: Include responses to all questions of the attached questionnaire (including documentation when requested). Include Statement of Assurances signed by an individual authorized to make binding arrangements on behalf of Applicant. Responses should be clear, complete and concise to allow for an adequate understanding of your Application and the information contained therein. The evaluation and selection procedures will be performed under the direction of the Collaborative Steering Committee. Final selection will be made by evaluators at First Choice and the HCA. Successful applicants will be presented with an Award Agreement which is a prerequisite for distribution of funds by First Choice or the HCA. No funds will be disbursed to parties unable or unwilling to sign the Award Agreement. The Award Agreement will outline: Agreement to complete the scope of work under the project as described in the application (including adherence to timeline, planned outcome of project implementation, and support of grant goals). Agreement to comply with monitoring processes designed to insure proper use of funds. Statement of Assurances I make the following certifications on behalf of the Applicant named herein: As an individual authorized by the Applicant to make binding agreements, I make the following statement of assurances as a required element of this Application. On behalf of the applicant, I understand that the truthfulness of the facts affirmed here and the continuing compliance with these requirements are conditions precedent to review of this Application and subsequent potential award: Applicant warrants that, in connection with this Application: All information presented in this proposal is true, correct, and complete to the best of applicants knowledge. None of the funds requested in this application are requested for duplicate or equivalent budgetary items (i.e. equipment, salaries, consulting) for which funding from another source is being provided. Applicant is not requesting funding aside from that necessary to pay for services specifically earmarked in the Application, and that costs for such services do not exceed those that would be paid by a prudent person for same or similar services. Applicant acknowledges that the submission of a timely and complete application in no way guarantees award or receipt of funds from First Choice Health or the Washington State Health Care Authority. Applicant certifies agreement to all the terms and conditions of this application including, but not limited to the discretionary nature of a decision by either First Choice Health or the Health Care Authority to not award funds or to award funds at a particular funding level. Applicant acknowledges that submission of false or misleading information will automatically disqualify this application from further consideration. Signature Date ____________________________________ Title ____________________________________ Applying Organization Please read the entire Application before completing the questionnaire. It contains important information necessary for a successful submission. 2007Application Questions Background Information 1. Organization Name:  FORMTEXT       2. Please describe your practice or facility. Please address the following elements: Description:  FORMCHECKBOX  Primary practice  FORMCHECKBOX   FORMCHECKBOX Specialty Practice  FORMCHECKBOX   FORMCHECKBOX Critical Access Hospital Size and nature of practice or facility (numbers of providers, corporate structure).  FORMTEXT       Patients (mix of payers and size of active panel):  FORMTEXT       Community partners:  FORMTEXT       3. Amount of Requested Funds:  FORMTEXT       4. Principal Contact Information: Name FORMTEXT       Phone number(s)  FORMTEXT       Fax number (s)  FORMTEXT       E-mail address  FORMTEXT       6. Are you a applying for funding from First Choice Health? (Must be member of the First Choice Health network)  FORMCHECKBOX Yes  FORMCHECKBOX No 7. Are you applying for funding from the Washington State Health Care Authority (HCA)?  FORMCHECKBOX Yes  FORMCHECKBOX No Planning Please describe the nature of your project and the driving forces behind it.  FORMTEXT       Please outline your expectations of costs, timelines, ROI, and necessary practice redesigns involved in this project.  FORMTEXT      Please list the key goals you expect this project to help your practice achieve.  FORMTEXT      What specific features within the Health IT system/solution will support achieving these goals?  FORMTEXT      How and when you will know your goals are being met?  FORMTEXT      Attach a document of signatures indicating current consensus on moving forward with your Health IT project.Attach a copy of the strategic business plan for the practice (if available). Does your organization use any Evidence Based Care tools?  FORMTEXT      Health IT SelectionWhat process and criteria were used to make the final Health IT selection for your organization (or used up to this point)? Which vendor systems/tools were considered?  FORMTEXT      Who was (will be) involved in the final decision?  FORMTEXT      Finances and Budget  Please attach copies of your organizations detailed budget for the Health IT project. Please identify the specific line items for which you are requesting funding. Please explain how you intend to fund this Health IT implementation project outside of funding for which you are applying. 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FORMTEXT      Which features and capabilities of the Health IT system are planned for implementation immediately? Which will be implemented at a later time period and what is that timeframe?  FORMTEXT      Which workflows do you hope to impact the most as a result of this project?  FORMTEXT      What interfaces or integration will be included as part of your Health IT implementation? Who has responsibility for developing any needed interfaces?  FORMTEXT      Please provide a copy of your practice s project plan including the implementation timeline for this project. (Please see the document  Determining If Your Practice is Ready for Health IT Adoption located at  HYPERLINK "http://www.wahealthinfocollaborative.org/#How" www.wahealthinfocollaborative.org/#How for elements of a project plan).Grant GoalsWill your project directly support sharing of clinical data to improve patient care? If so, how?  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