2018/02/07 Council Agenda Packet

BEHAVIORAL HEALTH SERVICES CERTIFICATION APPLICATION MATERIALS INCLUDED IN THIS APPLICATION Please indicate which document(s)you are including by checking the applicable box All applicants must submit: ❑ An electronic and/or hard copy of Administrative Policies and Procedures required by WAC 388-877,and Clinical Policies and Procedures for each service for which you are applying for under WAC 388-877A,WAC 388-877B, and/or WAC 388-877C. O DBHR's Policy and Procedure Review Tool for Providers found at https:I/www.dshs.wa.qovlbhaldivision-behavioral-health-and- recoverv/lrcensinq and certification-behavioral health a.encies,under the dro•down titled Technical Assistance Tools. If you are applying for Opiate Treatment Program(OTP)certification,you must submit: O An OTP Addendum form(CS-21-A). ❑ An OTP Community Relations Plan(CS-21-D). Copies of these forms are available by contacting the Certification Policy Manager,Jessica Blose at(360)725-3716 or Jessica.BloseAdshs.wa.gov,or by submitting a request in writing to:Certification Policy Manager, DSHS/DBHR, PO Box 45330, Olympia,WA 98504-5330. If you are applying for detoxification or residential treatment services certification,you must submit (unless not required, e.g.,your facility is on federal land or Veterans Administration affiliated): ❑ A copy of the residential treatment facility or hospital license issued by the Washington State Department of Health(DOH),Health Systems Quality Assurance(HSQA)Office of Customer Services. ❑License enclosed 0 License mailed at a later date APPLICANT DECLARATIONS I declare the following: • That I will notify DBHR if changes occur in any of the information provided in SECTIONS I and/or II of this application before licensure and certification is granted. • That no person named in this application has had a license or certification for a treatment service or health care agency denied, revoked,or suspended. WAC 388-877-0335(1)(d)(i) • That no person named in this application has been convicted of child abuse or adjudicated as a perpetrator of substantiated child abuse. WAC 388-877-0335(1)(d)(ii) • That no person or business entity named in this application is currently debarred,suspended, proposed for debarment,declared ineligible,or voluntarily excluded from participating in transactions involving certain federal funds. WAC 388-877-0335(1)(d)(xiii) • That no person or business entity 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 RCW 18.130.180. WAG 388-877-0335 (1)(d)(v). • 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 Legal Representative Date signed Printed name of person signing form Title Mailing address of person signing form Street City State Zip Phone number of person signing form Fax number of person signing form E-mail address of person signing form APPLICANT CONTACT INFORMATION ❑ Check here if same as above; if different, complete the information below Applicant's contact name Title Mailing address Street City State Zip Revised 10/5/17 Page 4 of 8