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State of Washington <br /> ht Washington State Department of Social and Health Services <br /> Department of Social <br /> 7 &Health services Division of Behavioral Health and Recovery <br /> Transforming lives <br /> OPIATE TREATMENT PROGRAM <br /> APPLICATION ADDENDUM <br /> Applicant: Use this form as an addendum to a DBHR application for certification as a new opiate treatment program, for <br /> a branch location, or for adding a service to an existing certified chemical dependency service program, and to identify the <br /> required federally recognized opiate treatment program (OTP)accreditation body. <br /> Please complete PARTS I.through VII.of the application addendum form, return the form with the completed information <br /> and the required materials with your new provider, branch, or added service application to the DBHR address listed at the <br /> end of this application addendum. <br /> I. PRE APPLICATION REQUIRMENT <br /> An OTP Community Relations Plan is required to be submitted to and approved by DBHR prior to submission of an OTP <br /> application. <br /> ❑ The OTP Community Relations Plan has been submitted and approved. <br /> II. AGENCY INFORMATION <br /> Name of Agency/OTP: <br /> Address of OTP: <br /> III. APPLICATION TYPE <br /> Check one: <br /> This addendum was included with an application for: <br /> ❑ Certification as a New Chemical Dependency Service Provider. <br /> If applying for certification as a new Washington State chemical dependency service provider, ensure the policy and <br /> procedure manuals submitted with your application meets the requirements of 42 Code Federal Regulations (CFR) <br /> Part 8.12-Certification of Opioid Treatment Programs. <br /> ❑ Certification for a New Branch of an existing Certified Chemical Dependency Service Provider. <br /> ❑ Certification for an Added Service of an existing Certified Chemical Dependency Service Provider. <br /> If applying for certification to provide opiate substitution treatment at a currently certified Washington State chemical <br /> dependency service facility, ensure the policy and procedures manuals submitted with your application meets the <br /> requirements of 42 CFR Part 8.12- Certification of Opioid Treatment Programs. <br /> ❑ Certification for a Relocation of an existing Certified Chemical Dependency Service Provider. <br /> OTP Application Addendum—04/18/2017 <br /> Page 1 of 6 <br />