Independent Facilitator Conflict of Interest Disclosure

Exhibit C

Independent Facilitator Conflict of Interest Disclosure

As a PIHP, the Lakeshore Regional Entity (LRE) must assure that Independent Facilitators contracted with the LRE are independent and/or external of the Michigan Community Mental Health System.These conflicts of interest include, but are not limited to the following:

1. The independent facilitator has no financial interest in the outcome of the supports and services outlined in the person-centered plan.
2. The independent facilitator is independent of or external to the community mental health system.
3. The independent facilitator must not have any other role within the PIHP/CMHSP.
4. An organization contracting with the PIHP or CMHSP must not provide independent facilitation services for individuals receiving supports and services from their organization.
5. An advocacy organization contracted with the LRE to provide independent facilitation services cannot provide those services for an individual/family they are advocating for with the PIHP or CMH system.
6. An independent facilitator cannot provide independent facilitation services for their child or family member, and receive reimbursement from the LRE for that service.

As an Independent Facilitator I agree to disclose any, and all potential or real conflicts of interest which could preclude me from providing independent facilitation services for the LRE. I agree to contact the LRE immediately should the circumstances below change. Please answer the following questions to determine a potential or actual conflict of interest:

1. Are you employed by a Michigan PIHP? Yes ☐ No ☐

If yes, which one and in what role?

1. Are you employed by a Community Mental Health Services Program (CMH)?

If yes, which one and in what role? Yes ☐ No ☐

1. Are you employed or subcontracted with a provider contracted with the LRE or one of the following CMHs: Yes ☐ No ☐

• Allegan County Community Mental Health Services
• CMH Services of Ottawa County
• HealthWest (Muskegon CMH)
• network180 (Kent CMH)
• West Michigan CMH System (Lake, Mason, Oceana CMH)

1. Which provider are you employed or subcontracted?

What is your title or the work you do?

1. Are you employed or subcontracted with an advocacy organization? Yes ☐ No ☐

If yes, which one and in what role?

1. Are you employed or subcontracted with the Michigan Department of Health and Human Services (MDHHS) Behavioral Health and Developmental Disabilities Administration? Yes ☐ No ☐

If Yes, what is your role?

I have read and answered the questions above to the best of my knowledge. The LRE may contact me for additional information to determine whether a conflict of interest exists, and how the conflict of interest may be addressed. The LRE reserves the right to terminate my contract to provide independent facilitation services should a conflict of interest exist.

Name: ______Signature: ______

Date: ______