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Please send SECTIONS I, II, and III of the completed application, required application materials, and the <br /> $1,000.00 application fee by check or money order payable to Department of Social and Health <br /> Services to: <br /> If sending by US Postal Service: For UPS or FedEx Delivery: <br /> BHA- Budget & Finance BHA- Budget& Finance <br /> Department of Social & Health Services Department of Social & Health Services <br /> PO Box 45525 Blake Office Park East <br /> Olympia, WA 98504 4450 10th Ave SE <br /> Lacey, WA 98503 <br /> If sending SECTION III later than SECTIONS I and II, please send SECTION III directly to: Provider Request <br /> Manager, Division of Behavioral Health and Recovery, PO Box 45330, Olympia,WA 98504-5330,or by email to: <br /> dbhrproviderrequestsAdshs.wa.gov. <br /> If you have questions about this form or its requirements, contact the Provider Requests Manager at the above <br /> email address. <br /> • <br /> Revised 10/5/17 Page 8 of 8 <br />