INSTRUCTIONS FOR COMPLETING
APPLICATION FOR A CHANGE IN OWNERSHIP
OF A CERTIFIED CHEMICAL DEPENDENCY SERVICE PROVIDER
INTRODUCTION
Washington Administrative Code (WAC) 388-805-005 defines a change in ownership as meaning
one of the following conditions:
(1)
When the ownership of a certified chemical dependency treatment provider changes
from one distinct legal entity (owner) to a distinct other;
Note: This usually means when a new set of owners takes over the organization from a
former set of owners.
(2)
When the type of business changes from one type to another; or,
Note: This usually means when an existing owner changes the type of business such as
from a sole proprietorship to a corporation.
(3)
When the current ownership takes on a new owner of five percent or more of the
organizational assets.
Note: This usually means that an existing owner is adding either new partners or new
stockholders of an existing organization.
Change in ownership application requirements are detailed WAC 388-805-105. Applications are
screened for completeness in the order received. If applications are found to be incomplete,
processing is suspended until we receive all the required information. Complete applications are
assigned to Division of Alcohol and Substance Abuse (DASA) Certification Specialists for review in
the order received. A DASA Certification Specialist will conduct an initial review for content within 30
days from the date received. An approval decision will be made at that time.
A separate application needs to be completed for each separate location at which services are
proposed to be delivered.
Return the completed original application form, one copy of the items required in PART 5, and the
nonrefundable $500 application fee to the attention of:
DASA Certification Provider Request Manager
Division of Alcohol and Substance Abuse
Post Office Box 45330
Olympia, Washington 98504-5330
Make your check or money order payable to Department of Social and Health Services. Please do
not return these instructions with your application.
You are encouraged to submit a complete application, including all policies, procedures (if
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applicable), and other documentation as early in the application process as possible. However, you
may wish to wait to obtain your facility and staff to avoid incurring facility and staff costs while your
application is pending review and approval.
Certification will be granted only to applicants demonstrating that they are prepared to operate
in compliance with all applicable federal, state, and local regulations.
Significant deficiencies can result in delays of department approval. The application form and
required materials are tools for evaluating applicant readiness for certification. The reviewing
DASA Certification Specialist will determine if the extent of the deficiencies must be corrected
prior to certification or as a part of a corrective action process following approval.
PART 1 – CURRENT PROVIDER AGENCY INFORMATION
1. Enter the eight digit agency number in the boxes provided. If you are ensure of the agency
number, it can be found with your agency listing in the Directory of State Certified Chemical
Dependency Treatment Services in Washington State.
2. Enter the name of the agency to be certified, as you would want it listed in the Directory of
State Certified Chemical Dependency Treatment Services in Washington State.
3. Use the second line to print additional organizational titles necessary for a correct address.
(For example, for the Division of Alcohol and Substance Abuse, the second line might read
Certification Section).
Example:
Addiction Recovery Services (1st line)
ABC Medical Center (2nd line)
Or,
ABC Medical Center (1st line)
Addiction Recovery Services (2nd line)
PART 2 –TYPE OF OWNERSHIP CHANGE
4.
This section is to indicate the type of ownership change to occur at your agency. Please
review the five choices and indicate the one that best fits the change in ownership at
your organization.
a.
Check this one if your current business organization is a private corporation and
if you are only adding one or more stockholder(s) of 5% or more of the corporate
stock.
b.
Check this one if your current business organization is a private partnership and
if you are only adding one or more partner(s) who will own 5% or more of the
organizational assets.
c.
Check this one if your current business organization is a private limited liability
company and you are adding one or more partner(s) who will own 5% or more of
the organizational assets.
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d.
Check this one if you are changing the type of ownership without adding any new
owner(s) of 5% or more of the organizational assets.
e.
Check this one if you are transferring ownership from one or more existing owner
of 5% or more of the organizational assets to a new set of owners.
PART 3 – NEW OWNERSHIP INFORMATION
5. Check box 5a if the new provider will retain and use the same agency name. If not, then
check box 5b.
6. Indicate the name of the agency to be certified, as you would want it listed in the next edition
of the Directory of State Certified Chemical Dependency Treatment Services in Washington
State.
7. Use the second line to add additional organizational titles necessary for a correct
address. (For example, for the Division of Alcohol and Substance Abuse, the second line
might read Certification Section).
Example:
Addiction Recovery Services (1st line)
ABC Medical Center (2nd line)
Or,
ABC Medical Center (1st line)
Addiction Recovery Services (2nd line)
Type of New Ownership (if applicable)
This applies only to changes that will result in a new legal entity owning the organization.
Those organizations that indicated the type 4 or 5 change in ownership 4 in Part 2 must
provide the following information:
Determine whether the ownership of the new provider to be certified is public or private.
8.
Put a check mark in the box that represents the provider’s type of ownership.
Print the name of the owner in the space provided to the right of the box.
Publicly-owned:
•
For city government, indicate the name of the city;
•
For county government, indicate the name of the county;
•
For state government, indicate the name of the state agency seeking certification,
such as Juvenile Rehabilitation Administration, or Department of Corrections;
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•
For federal government, indicate the name of the federal agency seeking
certification, such as Department of the Army, Department of Veterans Affairs, or
Department of the Navy;
•
For tribal government, indicate the name of the tribe;
•
For a health district, indicate the name of the health district, such as Spokane
Regional Health District;
•
For an educational service district, indicate the name of the service district, such
as ESD 114;
•
For municipal court probation, indicate the name of the city and municipal court;
•
For district court probation, indicate the name of the county and district court.
Privately-owned:
•
For sole proprietorship, indicate the name of the sole proprietor;
•
For partnership, indicate the name of the partnership or partners;
•
For a limited liability company, indicate the name of the company;
•
For a non-profit or for profit corporation, indicate the corporate name.
Note: The name of a privately owned organization should be the same as listed on the
Washington State Master Business License.
All New Providers:
9.
Enter the provider’s Federal Employer Tax Identification Number (FEIN). Sole
proprietors may use their Social Security Number (SSN) instead. Check the box to
indicate if the number provided is an FEIN or SSN.
Note: If the agency is changing legal entities or types of business ownership there may
be a new FEIN or SSN.
10.
Print the name and title of the person or entity that is the final authority for your
organization and will be responsible for meeting the governing body requirements of
WAC 388-805-140.
Note: This can be an entity such as a tribal council, county commissioners, corporate
board, etc.
Privately owned providers only:
11.
Enter the Washington State Uniform Business Identification (UBI) Number listed on the
applicant’s Washington State Master Business License in the boxes provided.
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PART 3 – CERTIFIED CHEMICAL DEPENDENCY SERVICES
Detoxification or residential service certification:
12.
Put a check mark by each service the new owner is seeking the transfer of certification.
Then indicate the total number of beds for each service requested. If the new owner
intends to focus the provision of services to a special group such as youth, women,
offenders, adults, etc., then indicate the special treatment focus in the space provided.
Non-residential service certification:
13.
Put a check mark by all the services for which the new owner is seeking the transfer of
certification. Then indicate the estimated number of persons your agency believes will
be served annually under the new ownership for each service requested. If the new
owner intends to focus the provision of services to a special group such as youth,
women, offenders, adults, etc., then indicate the special treatment focus in the space
provided.
A listing of services will continues to be published in the Directory of State Certified Chemical
Dependency Treatment Services in Washington State if the reviewing certification specialist
approves the transfer of certification to the new owner.
PART 4- CONTRACTS
14.
Check the yes or no box to indicate whether or not the organization currently receives
government funds to provide chemical dependency services or if the new management
intends to provide services funded by the government.
15.
If item 14 is yes, then list the source(s) of the funds, e.g., federal, state, tribal, county,
criminal justice, or corrections.
16.
Also, list the certified chemical dependency treatment service(s) for which government
funds are or may be provided.
PART 5 – MATERIALS TO BE SUBMITTED WITH THE APPLICATION
A.
If you are adding one or more stockholder or partner to either a for-profit
corporation, partnership, or limited liability company then submit the following
information:
1. If privately owned, submit a copy of the report of findings from a criminal
background check as conducted by the Washington State Patrol and the last state of
residence if the person has lived out-of-state within the past three years for any new
owner of five percent of the organizational assets. The background results must
have been completed within the two years before the receipt of the application.
2. If privately owned, submit a list (as applicable) with the name, address, phone
number, and percentage of ownership for each new owner of five percent or more
of the organizational assets.
Example:
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Name
John Doe
Address
123 Recovery Ln.
Oxford, WA 98123
Telephone #
(509) 123-4567
Ownership Percentage
25%
B. If you are changing the type of ownership or transferring ownership from existing
owners to new owners then please submit the following information:
1. Submit a complete list (as applicable) with the name, address, phone number, and
title of each member of the organizational governing body. The organizational
governing body consists of those persons who are responsible for the management
of the organization and have the final decision making authority. This could be a
member of a corporate board, members of a tribal council, members of a city council,
or county commissioners.
Example:
Name
Jane Doe
Address
321 Recovery Ln.
Oxford, WA 98123
Telephone #
(509) 765-4321
Title
Board President
2. If privately owned:
a. Submit a list (as applicable) with the name, address, phone number, and
percentage of ownership for each new owner of five percent or more of the
organizational assets.
Example:
Name
John Doe
Address
123 Recovery Ln.
Oxford, WA 98123
Telephone #
(509) 123-4567
Ownership %
25%
a. Submit a copy of the report of findings from a criminal background check as
conducted by the Washington State Patrol and the last state of residence if the
person has lived out-of-state within the past three years for any new owner of five
percent of the organizational assets. The background results must have been
completed within the two years before the receipt of the application.
b. Submit a copy of the Washington State Master Business License (as applicable),
which authorizes the applicant to do business in this state.
3. Check box 3a if the new governing body intends to appoint a new agency
administrator for the organization, list the name and title of the new administrator.
and submit a copy of the report of findings from a criminal background check, as
conducted by the Washington State Patrol and the last state of residence if the new
administrator has lived outside of Washington State within the past three years.
Check box 3b if the current administrator will be retained.
4. Check box 4a if the administrator intends to appoint a new clinical supervisor,
list the name and title of the new supervisor, and provide a copy of his or her current
Certificate of Certification as a Chemical Dependency Professional issued by the
Department of Health. If not, check box 4b no,
5. Check box 5a if the new governing body decided to approve and adopt the
existing agency policies and procedures. If not, check box 5b no, then submit a
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complete copy of the new agency administrative, personnel, and clinical policy and
procedure manuals specific to the organization, agency, and treatment services that
will be in force within the agency at the time of the change in ownership.
6. Check box 6a if the new governing body has adopted the existing agency fiscal
policies and procedures. If not, then check box 6b and submit a complete copy of
the new fiscal policies and procedures, as they relate to informing clients and
patients of the fees to be charged for services, that will be in force within the agency
at the time of the change in ownership.
7. If the new governing body will not be retaining the same chemical dependency
professional staff that are employed by the current organization, then submit
the following evidence of sufficient qualified staff to deliver the chemical dependency
treatment services that will be provided under the new ownership.
a. An organizational chart showing each staff position, including volunteers,
students, and persons on contract, by job title, lines of responsibility, the full-time
equivalency percentage for each position, and how the agency relates to any
parent organization.
b. A copy of the job description for the on-site administrator and each staff person
who will be providing or supervising patient care.
c. A copy of the current certificate as a chemical dependency professional issued
by the Washington State Department of Health (DOH) for each chemical
dependency professional (CDP) to be employed by your organization at the
proposed initial site. The wall certificate issued by DOH is not sufficient. The
copy of the certificate must include the certification expiration date.
d. If applying as a municipal or district court probation office, submit evidence
of the employment of a probation assessment officer (PAO) that meets the
requirements of WAC 388-805-220. Evidence should include copies of course
transcripts, and training documentation, verification of supervised experience as
a PAO trainee, and documentation of continuing education as required.
e. If the organization is currently certified to provide alcohol/drug information
school services and the new governing body intends to continue providing
that service, then submit evidence of the employment of a qualified alcohol/drug
information school instructor that meets the requirements of WAC 388-805-250.
Acceptable evidence includes a copy of an individual’s DASA issued Certificate
of Qualification as an Alcohol/Drug Information School Instructor.
C. All Applicants:
1. An application fee of $500 must be submitted with this application, and must be in the
form of a check or money order made out to the Department of Social and Health
Services.
2. Submit a copy of the cover letter used to notify the county alcohol/drug coordinator
where services will be provided, and a completed copy of the application form. Only
send a copy of the application form itself. You do not need to provide the county
coordinator with a copy of the application materials (manuals, licenses, staff
certifications, etc.).
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The alcohol and drug coordinator coordinates the delivery of publicly funded chemical
dependency services in his/her respective county.
PART 6 – DECLARATIONS
Ensure you read the declarations carefully, and that both the former owner and new owner (as
applicable) complete the signature block.
If there are any questions about this application, contact the DASA Certification Provider
Request Manager at (360) 725-3728, Toll Free 1-877-301-4557, or by e-mail at
anderrd@dshs.wa.gov.
(f:\shared\certific\forms\123b, revised 6/4/2009)
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