AGENCY NAME: AGENCY CODE: SCHOOL CODE: (SED ONLY)General Information Form • August 24th, 2009
Line COLUMN NUMBER Cost No. ITEM DESCRIPTION Codes SECTION A: GENERAL INFORMATION 1 Program Type 00070 2 Program Code (Program Code Index) 00010 ( ) ( ) ( ) ( ) ( ) 3 Program/Site Identification Number 00050 4 Program/Site Name 00020 5 Program/Site Address (Line One) 00030 6 Program/Site Address (Line Two) 00040 7 Medicaid Provider Agreement Number (DMH only) 00060 8 County Code (See Appendix C) 00080 9 Date Site Opened 00090 10 Certified Capacity (OASAS and OMRDD only) 00100 11 Actual Capacity (OMH and OMRDD only) 00110 12 Actual Days Program/Site Open 00160 13 Units of Service 00120 14 Respite or TUBS Units of Service (OMRDD only) 00130 15 Program/Site Square Footage (OASAS and OMRDD only) 00150
