We’re grateful for your interest in partnering with Region Five Mobile Crisis Response. Use the form below to begin the MOU process and our team will contact you with next steps.

Before you get started, make sure you have the required documentation, including your fully completed VCC Provider Roster (staffing spreadsheet). If you do not have this done yet, go here to download the excel.

All documents needed:

• A current copy of Licensure with addendum for Licensed As: A mental health non-center-based community crisis service for children adolescents, and/or adults
• A current copy of insurance
• VCC Provider Roster with staffing plan spreadsheet (supplied by the Hub). This excel needs to be downloaded and completed fully with a realistic staffing plan that shows dispatch availability of 24/7 response (it can not just say ‘24/7’ in the Hours.) When you have finished completing the excel, download it and attach it to your application.
• Copy of MOUs with any other Hub
• Copy of attestation of enrollment as a Medicaid Provider (This is your DMAS letter that you are enrolled with DMAS. If you do not have it yet, you have 60 days to provide the letter once the MOU has been completed.)