Free Microsoft Word - 48161.DOC - Indiana

APPLICATION FOR CERTIFICATION OR LICENSURE
State Form 48161 (R3 / 7-06) / CM 0001 Indiana Family and Social Services Administration Division of Mental Health and Addiction INSTRUCTIONS: 1) Complete original application and attachments. 2) .Forward to address in upper right corner of form. Certification and Licensure 402 West Washington Street, Room W353 Indianapolis, IN 46204-2739

I. GENERAL INFORMATION Information about the applicant agency is requested in this section. Information about ownership is required as stated in the attachments. Legal name of applicant agency DBA name of agency, if different Employer Federal ID# Chief Executive Officer 1. Applicant Agency:
Organization Structure of Applicant Agency. (Check One:) Governmental Entity Private Nonprofit Private for Profit

2. Community Mental Health Center (if different person) :

Main business office location address and telephone number of applicant agency (Number and Street. Note: A post office box number is not considered a location.) City, State, ZIP code, and County Telephone Number, Fax Number, and E-mail or Internet Address Mailing address of applicant agency, if different from location address Street or Post Office Box Number, City, State, and ZIP

II. CERTIFICATION/LICENSURE Check all boxes that apply within one category and indicate whether this is an application for a new certification/license or a request for renewal. TYPE OF CERTIFICATION OR LICENSE
SERVICE PROVIDER APPLICATION: Community Mental Health Center (CMHC) Private Mental Health Institution/Inpatient (PIP) Addiction Services Provider (AS) Residential Care Provider (RCP) 1 Subacute Stabilization Facility Supervised Group Living Facility MANAGED CARE PROVIDER (MCP) APPLICATION: Indicate population below. MCP ­ SMI (Seriously Mentally Ill) MCP ­ SED (Seriously Emotionally Disturbed Children) MCP ­ CA (Chronically Addicted) MCP -- GAM (Compulsive Gambling Addiction)
1

RULE

RENEW

NEW

440 IAC 4.1 440 IAC 1.5 440 IAC 4.4 440 IAC 6 440 IAC 7.5 440 IAC 7.5

440 IAC 4.3 440 IAC 4.3 440 IAC 4.3 440 IAC 4.3

Community Mental Health Centers and Managed Care Providers are deemed Residential Care Providers.

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III. RESIDENTIAL SETTINGS - 440 IAC 7.5 Indicate residential settings which are operated by the applicant agency. Setting Supervised Group Living Facility (SGL) Subacute Stabilization Facility Transitional Residential Facility (TRS) Alternative Family for Adults Program (AFA) Semi-Independent Living Program (SILP) IV. ACCREDITATION List all accrediting agencies applicable to requested licensure/certification. A copy of the complete accreditation report must be included before the application will be processed. Accrediting Agency Date of Survey Effective Dates of Accreditation From: To: Status of Accreditation1 Program Standards or Manual2 Number of Facilities Total Number of Beds

From:

To:

1 2

Status of Accreditation: Indicate type of accreditation received, whether corrections are needed, and follow-up time. Indicate inpatient, outpatient, residential (non-inpatient), addiction treatment etc.

Has the applicant agency applied for accreditation and been denied accreditation by an accrediting agency in the last 24 months? YES NO If YES, give accrediting agency name and date of decision.

V. ATTACHMENTS Submit the required attachments required for each certification/license. Label all documents to correspond to the Attachment List. All applicants except Managed Care Provider applicants must complete a Facility Facts Record for each location operated by the applicant agency. Managed Care Providers must complete a Chart of Provider Panel Members. VI. GENERAL CONDITIONS Upon certification/licensure for the requested service(s) and/or setting(s), the applicant agrees to abide by all laws, rules and administrative directives governing the certified/licensed service(s). THE APPLICANT AGREES TO GIVE THE REQUIRED WRITTEN NOTICE OF CHANGES TO THE DIVISION OF MENTAL HEALTH AND ADDICTION. The Division of Mental Health and Addiction may require a new application as a result of such changes. The applicant affirms that the statements and declarations contained herein are true and correct to the best of the applicant's knowledge. Applicant Agency Signature (Individual with signature authority) Type or print the name of the signatory Date (month, day, year) Official Title

RETURN THIS APPLICATION FORM AND ALL REQUIRED ATTACHMENTS TO ADDRESS ON FACE OF FORM

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