Dear AWC FMS Provider,

This is to notify you of the individuals included in the AWC FMS Provider Monitoring sample. Your sample contains 10 initial (primary) and 5 back-up (alternate) individuals whose records you are to review as part of the Self-Reporting phase of the Office of Developmental Programs (ODP) AWC FMSProvider Monitoring process. If you no longer provide services to one or more of the individuals in your sample, please replace that sample individual with one (starting at the top) of the sample individuals in the Back-up list.

Initial (Primary) Sample

MCI Number
MCI #
MCI #
MCI #
MCI #
MCI #
MCI #
MCI #
MCI #
MCI #
MCI #

Back-up (Alternate) Sample

MCI Number
MCI #
MCI #
MCI #
MCI #
MCI #

You must complete the applicablemonitoring tool and submit the tool to ODP via the electronic toolby December 15, 2016. A unique link to the electronic toolwill be sent via email from the AWC Provider Monitoring mailbox to the primary contact person’s e-mail address by October15, 2016. As a provider, you are required to utilize this link to access and complete the tool.

You must retain all supporting documentation used to complete the tool during the Self-Reporting phase in order for the AE to validate your responses during the On-site Review phase. The inability to produce such documentation when requested during an on-site reviewwill be considered non-compliant and the AE and/or ODP may seek enforcement measures accordingly.

Please continue to check the AWC FMS Provider Information materials on the ODP website at www.MYODP.org website under URL link to guide you as you complete this process.

Thank you for your participation in ODP’sAWC FMS Provider Monitoring process.

If you require assistance, please contact me at AE Representative's contact information.

Sincerely,

Name/Title of Lead AE

cc: Reviewing AEs

AWC Sample Letter: Self-Reporting onlyLast updated: 10/26/16