Region 7 IDN Sub-Recipient Concept Paper Cover Sheet Please read through the entire cover sheet and instructions before you begin the application process. This form should be saved to your computer file before you complete it. You must complete the cover sheet in full and submit it along with the required attachments by 3 p.m. on the day of the deadline. E-mail is the preferred method of transmission.
Primary Applicant:	Click here to enter text.
Date:	Click here to enter a date.
Physical address: Click here to enter text.	Mailing address: (if different) Click here to enter text.
Telephone number: Click here to enter text.	Website: Click here to enter text.
Tax ID: Click here to enter text.	What is your corporate structure?
Which of the following best describes your organization type:
Has your organization completed a Certificate of Authorization?
Is your organization a Statewide Agency? If yes, please state how you will ensure your organization will not accept duplicative payments from multiple IDNs for providing the same services to the same beneficiary throughout a project activity. Click here to enter text.
Primary organization contact person:	Name: Click here to enter text.
Title: Click here to enter text.
Email: Click here to enter text.
Telephone number: Click here to enter text.
Organizational Capacity: Provide a brief overview (2-3 paragraphs) of your organization including mission, year founded, organization type and size. Click here to enter text.
Project Title: Click here to enter text.
Please select what funding category best addresses your project? (only pick one) – see region7idn.com for additional information on project criteria and metrics.	Make a funding selection from list below
The following are identified needs for Region 7 IDN. Please explain in a few sentences which need(s) you will be addressing in your proposal: Access to Mental Health Services Access to Primary Care Services Opioid Crisis Supportive Housing Addressing Social Determinants of Health (financial security, housing, education, social isolation, transportation, employment, legal)	Click here to enter text.
Budget dollars requested: Click here to enter text.
Project start date: Click here to enter a date.	Project end date: Click here to enter a date.
Purpose of funding request: The funding from Region 7 IDN will be used to… (please keep response to less than 25 words) - Click here to enter text.
Brief summary of proposal (300 words): Click here to enter text.
How does your proposed project align with the goals and objectives of the NH Delivery System Reform Incentive Payment (DSRIP) Program? (200 words) - (1) deliver integrated physical and behavioral health care that better addresses the full range of individuals’ needs; (2) expand capacity to address emerging and ongoing behavioral health needs in an appropriate setting; (3) reduce gaps in care during transitions across care settings by improving coordination across providers and linking Medicaid beneficiaries with community supports; and (4) Advanced Payment Models for 50% of Medicaid payments by 12/31/2020. Click here to enter text.
List 3 measurable outcomes you expect to achieve as a result of this funding: Click here to enter text. Click here to enter text. Click here to enter text.
Collaboration: Describe the collaborative relationships needed for the project to be successful, and who you will be partnering with, if anyone. Explain what partnerships have already been established, and what additional partners bring to the project. (250 words) Click here to enter text.