2018/02/07 Council Agenda Packet

Phone number Fax number E-mail address 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 as long as required by applicable law following the voluntarily cancellation of certification, and indefinitely in cases of involuntary cancellation, revocation, or suspension of certification. 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 more information: • DSHS public disclosure rules:WAC 388-01 • DSHS public disclosure law: RCW 42.56 • To Contact the DSHS Public Records/Privacy Officer: DSHSPublicDisclosure(aldshs.wa.gov END OF SECTION II: INITIAL APPLICATION FOR MAIN AGENCY BEHAVIORAL HEALTH SERVICES CERTIFICATION ❑Check if you are including FACILITY AND PERSONNEL INFORMATION,SECTION III,with this application. ❑Check if you plan to send FACILITY AND PERSONNEL INFORMATION,SECTION III,at a later date. Note:SECTION III of this application must be submitted,reviewed,and approved before licensing and certification can be granted. If checked,indicate the county in which you intend to provide the services: PLEASE NOTE: DBHR will not begin processing incomplete applications. Insure that all required items in Sections I and II are included in your initial application if sending Section III at a later time. Incomplete applications will be returned. Revised 10/5/17 Page 5 of 8