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For DBHR Use Only Amount Received $_________________ Date Received__________________ Check Number: _________ - Application Number: - Division of Behavioral Health and Recovery (DBHR) Department of Social and Health Services (DSHS) State of Washington APPLICATION FOR CERTIFICATION AS A NEW CHEMICAL DEPENDENCY SERVICE PROVIDER PART 1 OF 2– OWNER/PROVIDER INFORMATION I. APPLICANT PROVIDER INFORMATION Owner/Provider’s name: Private operators must use the name on your Washington State Master Business License. Public operators must indicate the name of the tribal, federal, state, county, or municipal government, health district, or educational service district under which the agency will operate. Check only one type of organization: Publicly Operated: Privately Operated: Municipal Government County Government State Government Federal Government Tribal Government Health District Educational Service District Other Sole Proprietorship Partnership Limited Liability Company Non-Profit Corporation For-Profit Corporation Employer Identification Number: Check the appropriate box and enter either your Federal Employer (Tax ) Identification Number (FEIN) or your Social Security Number (SSN). Note: Only sole proprietors may use their federal SSN: Federal Employer Tax Identification Number (FEIN): OR Social Security Number (SSN): - - Washington State—Uniform Business Identification Number (UBI). See http://www.dol.wa.gov/business/file.html - - AGENCY NAME This is the name you provide certified services under and it will be listed in the Directory of Certified Chemical Dependency Services In Washington State. Note: If you are a private provider, the name of the agency must be the same as the name listed on your Washington Master Business License. New Provider Application – revised 7/30/2010 Page 1 of 6 II. CHEMICAL DEPENDENCY SERVICES FOR WHICH YOU ARE APPLYING WAC 388-805-010 A. Detoxification Services Total Number of Beds Treatment Focus (Check all the apply) (For Each Service) (Limit to 10 characters. Leave blank if none) Detoxification – Acute Detoxification -- Sub acute B. Residential Services (Check all the apply) Total Number of Beds Treatment Focus (For Each Service) (Limit to 10 characters. Leave blank if none) Intensive Inpatient Recovery House Long-Term Treatment C. Outpatient Treatment Services (Check All That Apply) Estimated Number of Persons to be Served Annually (For Each Service) Treatment Focus (Limit to 10 characters. Leave blank if none) Intensive Outpatient Outpatient Opiate Substitution Treatment Program (OTP) D. Assessment Services Estimated Number of Persons to be Served Annually (Check All That Apply) (For Each Service) Treatment Focus (Limit to 10 characters. Leave blank if none) ADATSA (requires state/county contract) DUI Assessments Assessment Only (check if this is the only service you are offering; see FAQs) E. Information and Assistance Services (Check All That Apply) Estimated Number of Persons to be Served Annually (For Each Service) Treatment Focus (Limit to 10 characters. Leave blank if none) Alcohol/Drug Information School Information & Crisis Services Emergency Service Patrol Screening and Brief Intervention III. APPLICATION MATERIALS TO BE SUBMITTED A. Public Organizations -- Governing Body Application Materials: Provide the following information for the person delegated the responsibilities of the governing body specified in WAC 388-805-140. See http://www1.leg.wa.gov/CodeReviser/. Name of person: ____________________________________________________________________ Position title: _______________________________________________________________________ Mailing address: _____________________________________________________________________ Contact telephone number(s): ____________________________________________________________ B. Privately Operated Organizations -- Governing Body Application Materials: Note: The check boxes are for your use to check off as you include them with the application. If applying as either a for-profit or non-profit corporation, you must submit a copy of: The corporate Articles of Incorporation The corporate By-Laws The Certificate of Incorporation issued by the state of Washington, Secretary of State A list of each member of the corporate Board of Directors. Include each member’s mailing address, contact telephone numbers, a Washington State Patrol criminal background check and title of his or her position on the Board of Directors. If applying as a limited liability company, you must submit a copy of: The Membership Agreement The Certificate of Formation issued by the state of Washington Secretary of State A list of each member of the company. Include each member’s mailing address, contact telephone numbers, a Washington State Patrol criminal background check, and the title of their position in the company If applying as a partnership, you must submit a copy of: The partnership agreement A list of each general member of the partnership. Include each member’s mailing address and contact telephone numbers A copy of the report of findings from a Washington State Patrol criminal background check If applying as a sole proprietorship, you must submit a copy of: The statement of sole proprietorship The mailing address and contact telephone numbers for the sole proprietor A copy of the report of findings from a Washington State Patrol criminal background check New Provider Application – revised 7/30/2010 Page 2 of 6 C. Privately Operated Ownership Application Fee and Materials: All privately-operated providers must submit the following: A copy of the current Washington State Master Business License. Submit an application fee of $500 with this application. The fee must be in the form of a check or money order payable to the Department of Social and Health Services. (Only privately operated providers are required to submit an application fee.) All privately-operated providers other than non-profit corporations must submit a list of each owner of five percent (5%) or more of the organizational assets. Attach the following information for each owner(s): Name. Mailing address. Contact telephone numbers. Percentage of ownership. If the person has lived out-of-state within the past three years, list the last state of residence. A copy of the report of findings from a Washington State Patrol criminal background check. D. Additional Application Materials: All applicants must attach the following: A complete copy of your administrative, personnel, and clinical policies and procedures manuals specific to your organization, agency, and treatment services at the proposed site. A sample patient/student record for each chemical dependency service for which you are requesting approval in this application. A copy of the cover letter you sent to the County Alcohol/Drug Coordinator in the county where you intend to provide the services in this application. (Attach a copy of this application form to your letter to the County Alcohol/Drug Coordinator.) If applying for certification as an Opiate Treatment Program (OTP), attach the following: OTP Addendum form. OTP Community Relations Plan. For copies these forms, contact the Certification Section Policy Manager at (360) 725-3716, or e-mail at cummida@dshs.wa.gov, or submit a request in writing to Certification Policy Manger, DSHS/DBHR, PO Box 45330, Olympia, WA 98504-5330, or go to the DBHR web site at http://www1.dshs.wa.gov/DASA/ IV. APPLICANT DECLARATIONS I declare the following: That I will notify DBHR if changes occur in any of the information provided in Parts 1 or 2 of this application before certification occurs. That no person named in this application has had a license or certification for a chemical dependency treatment service or health care agency either denied, revoked, or suspended, as referenced in WAC 388-805-065(1)(a). That no person named in this application has been convicted of child abuse or adjudicated as a perpetrator of substantiated child abuse, as referenced in WAC 388-805-065(1)(b). That no person named in this application is currently under investigation for or has committed, permitted, aided or abetted the commission of an illegal act or unprofessional conduct as defined under Chapter 18.130.180 RCW, as referenced in WAC 388805-065(1)(d). That the information contained in this application and on all documents submitted with this application is true, accurate, and complete to the best of my knowledge. Signature of Administrator or other legal representative: Date of signature: Printed Name of Person Signing Form: Title: Mailing Address of Person Signing Form: City: Telephone Number of Person Signing Form: ( ) E-mail Address of Person Signing Form: New Provider Application – revised 7/30/2010 State: Fax: ( Page 3 of 6 ) Zip: V. APPLICANT CONTACT INFORMATION Check here if same as above; if different, complete the below Applicant’s Contact Name: Title: Applicant’s Contact Mailing Address: City: Contact Telephone Number: ( ) Contact E-mail Address: State: Contact Fax Number: ( ) Zip: Check if you plan to send PART 2 OF 2 – FACILITY AND PERSONNEL INFORMATION – SECTIONS I - III at a later date. Note: Part 2 of 2 of the application must be submitted, reviewed, and approved before certification can be granted. If checked, indicate the county you intend to provide services in: Privacy Notice This notice is provided in compliance with Governor’s Executive Order 00-03 and addresses the collection, use, security, and access to information obtained by your submission of this information to the Department of Social and Health Services, Division of Behavioral Health and Recovery (DBHR). DBHR requires an applicant who is applying for certification to provide chemical dependency services as a sole proprietor to submit a Federal Employer Tax Identification Number or their personal Social Security Number. The number is used to identify a specific person or legal entity that owns a specific business. All information collected as a part of the certification process for departmental approval is collected for considering applicant and provider compliance with applicable regulations related to their requests. All information is considered public information, and may be made available to anyone submitting a proper public information request unless exempted by the Public Information Disclosure Act under Revised Code of Washington (RCW) 42.56.230 through 290. Information may be retained for the period of provider certification to include any subsequent changes in provider ownership. The department will retain records for up to six years following the voluntarily cancellation of certification, and indefinitely in cases of involuntary cancellation, revocation, or suspension of certification. Information will be destroyed after that time. Persons submitting information have the right to review personal information on file with the department. You can recommend changes to your personally identifiable information you believe to be inaccurate by submitting a written request that credibly shows the inaccuracy. We will take reasonable steps to verify your identity before granting access or making corrections. For Questions or concerns: If you have any questions or concerns about your privacy protections, feel free to contact Dennis W. Malmer, DBHR Certification Supervisor, (360) 725-3718 or Toll Free 1-877-301-4557, or by e-mail malmedw@dshs.wa.gov. For more information: DSHS public disclosure rules (Washington Administrative Code 388-01): http://apps.leg.wa.gov/wac/ DSHS public disclosure law (RCW 42.56): http://apps.leg.wa.gov/rcw/ To Contact the DSHS Public Records/Privacy Officer: DSHSPublicDisclosure@dshs.wa.gov [END OF PART 1 OF 2– OWNER/PROVIDER INFORMATION] New Provider Application – revised 7/30/2010 Page 4 of 6 PART 2 OF 2 – FACILITY AND PERSONNEL INFORMATION Check if you sent Part 1 of 2 of the application at an earlier date. AGENCY NAME (as indicated on Part 1 of 2, Section 1 of this application): I. FACILITY INFORMATION AND MATERIALS A. Facility Information Street Address for the site to be certified and listed in the Directory of Certified Chemical Dependency Services in Washington State: City: County: State: Mailing Address to be listed in the Directory and used to send certified agency information/documents. City: Agency Telephone Number(s) (Include area code) to be listed in the Directory. List up to two numbers. Zip Code: Check if same as above: State: Zip Code: Fax Number (Include area code) to be listed in the Directory of Certified Programs: ( ) _____ Check if toll-free. ( ) _______ ( ) _____ Check if toll-free. E-Mail Addresses (optional): Administrator’s E-Mail: ___________@ __________________________ Do you want this published in the Directory? yes or no Agency Customer Service E-mail ___________@ ___________________ Do you want this published in the Directory? yes or no Agency web site: : _____________________________________________ Do you want this published in the Directory? yes or no B. Agency Materials. Attach the following: ALL APPLICANTS: A floor plan of the facility that shows the location where all certified chemical dependency services are to be provided and the dimensions of each room. See the sample floor plan provided with this application. The floor plan may be hand drawn. The reception area must be separate from all counseling and living areas. PRIVATELY OWNED (Non-government) APPLICANTS ONLY: A completed Accessibility Barrier Checklist for the site to be certified. Each element in the checklist must be marked yes, no, or not applicable (NA). Complete the corrective action plan section for any element marked ―no.‖ Incomplete forms will be returned. II. PERSONNEL INFORMATION AND MATERIALS A. Key Personnel Information and Materials. Administrator Name: Title: Submit the following materials regarding the person named as administrator with this form: A copy of the job description signed and dated by the person named. A copy of the report of findings from a Washington State Patrol criminal background check. A copy of the report of findings of a criminal background check from the last state of residence if the person has lived out-of-state within the past three years. Clinical Supervisor Name: Title: Submit the following materials regarding the person named as clinical supervisor with this form: A copy of the job description signed and dated by the clinical supervisor. A copy of the current Chemical Dependency Professional certificate issued by the Washington State Department of Health. Documentation of competency in clinical supervision. Alcohol/Drug Information School (ADIS) Instructor, if applying for ADIS certification. Name: When applicable, submit the following materials regarding the person named as ADIS Instructor with this form: A copy of the job description signed and dated by the person named. A copy of the current Chemical Dependency Professional certificate issued by the Washington State Department of Health, OR a copy of an Alcohol/Drug Information School Instructor certificate issued by the Washington State Division of Behavioral Health and Recovery. New Provider Application – revised 7/30/2010 Page 5 of 6 B. Other Personnel Materials. Attach the following: A copy of the agency organizational chart showing each staff position at the time of certification, including volunteers, students, and persons on contract, by job title, lines of responsibility, the full-time equivalency (FTE) percentage for each position, and how the agency relates to any parent organization. If an individual fills more than one position, the FTE should reflect the percentage of time that person anticipates working in each position. For example, a person holding the positions of administrator, clinical supervisor, and chemical dependency counselor, may be listed as .33 FTE administrator, .33 FTE clinical supervisor, and .33 FTE chemical dependency counselor A copy of a current Chemical Dependency Professional (CDP) certificate issued by the Washington State Department of Health for each CDP to be employed by your organization at the proposed site. And, check one: Certificate(s) Enclosed. Designated Clinical Supervisor will provide all certified chemical dependency assessment and treatment services. III. TREATMENT FOCUS INFORMATION The information in this section is voluntary and is not required for approval. This information will appear in the Directory of Certified Chemical Dependency Services in Washington State. The purpose of collecting this information is to provide patients and agencies information on the focus of the treatment or services you offer. It is helpful in making referrals and to best match the needs of the patient. A. Faith-based Information Do you want to be identified in the Directory as a faith-based organization under WAC 388-805-005? No. If no, go to Section B. Yes. Your agency will be listed as a faith-based organization the next time the Directory is updated. Note: If you are a faith-based organization, your policies and procedures manual must also address the requirements of: WAC 388-805-305(2). WAC 388-805-015(3). B. Accreditation Body Information Are you accredited by one of the accreditation bodies listed below? No. If no, go to Section C. Yes. If yes, check the organization you are accredited by? Commission on Accreditation of Rehabilitation Facilities (CARF) Council on Accreditation (COA) The Joint Commission National Commission on Correctional Health Care (NCCHC) Washington State Division of Behavioral Health and Recovery (DBHR). (This is available to OTP agencies only.) Do you want your accreditation listed in the Directory? No. Yes. If yes, attach a copy of your current accreditation certificate. Check if you want to be contacted about becoming a ―deemed agency‖ under WAC 388-805-115. C. Other Indicators that apply to your entire agency? Check any of the following boxes that apply to all services provided at your agency. You also have the option of adding any of these under ―Treatment Focus" to any service you have applied for in Part 1 of 2, Section II on Page 2 of 6 of this application form. NATIVE AMERICAN. ON-LINE REPORTING. PREGNANT & POST PARTUM. SPANISH. YOUTH. The agency is Tribal or Urban Native American-operated.) The agency reports data on DBHR’s TARGET on-line system. The agency serves women who are pregnant or post partum. Offers services in Spanish. All services are directed to youth under the age of eighteen (18) years. Submit the completed application form and materials to: Express Mail: Regular mail: DBHR Certification Provider Request Manager Division of Behavioral Health and Recovery 626 8th Avenue S.E. Olympia, WA 98501 Post Office Box 45330 Olympia, Washington 98504-5330 New Provider Application – revised 7/30/2010 Page 6 of 6