INSTRUCTIONS FOR COMPLETING

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					                       INSTRUCTIONS FOR COMPLETING
                 APPLICATION FOR A CHANGE IN OWNERSHIP
          OF A CERTIFIED CHEMICAL DEPENDENCY SERVICE PROVIDER

INTRODUCTION

Washington Administrative Code (WAC) 388-805-005 defines a change in ownership as meaning
one of the following conditions:

(1)     When the ownership of a certified chemical dependency treatment provider changes
        from one distinct legal entity (owner) to a distinct other;

        Note: This usually means when a new set of owners takes over the organization from a
        former set of owners.

(2)     When the type of business changes from one type to another; or,

        Note: This usually means when an existing owner changes the type of business such
        as from a sole proprietorship to a corporation.

(3)     When the current ownership takes on a new owner of five percent or more of the
        organizational assets.

        Note: This usually means that an existing owner is adding either new partners or new
        stockholders of an existing organization.

Change in ownership application requirements are detailed WAC 388-805-105. Applications are
screened for completeness in the order received. If applications are found to be incomplete,
processing is suspended until we receive all the required information. Complete applications are
assigned to Division of Behavioral Health and Recovery (DBHR) Certification Specialists for review
in the order received. A DBHR Certification Specialist will conduct an initial review for content within
30 days from the date received. An approval decision will be made at that time.

A separate application needs to be completed for each separate location at which services are
proposed to be delivered.

Return the completed original application form, one copy of the items required in Section VII.C, and
the nonrefundable $500 application fee to:

        If sending by mail:                                     For UPS or FedEx Delivery:

        Finance Office                                          Finance Office
        Aging & Disability Services Administration              Aging & Disability Services
        Administration
        Department of Social and Health Services                Department of Social and Health
        Services
        PO Box 45600                                            Blake Office Park West
        Olympia, WA 98504-5600                                  4450 10th Ave SE
                                                                Lacey, WA 9850

Make your check or money order payable to Department of Social and Health Services. Please do
not return these instructions with your application.

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You are encouraged to submit a complete application, including all policies, procedures (if
applicable), and other documentation as early in the application process as possible. However, if
changing agency location and/or staff, you may wish to wait to obtain your facility and staff to avoid
incurring facility and staff costs while your application is pending review and approval.

Certification will be granted only to applicants demonstrating that they are prepared to operate in
compliance with all applicable federal, state, and local regulations.

Significant deficiencies can result in delays of department approval. The application form and
required materials are tools for evaluating applicant readiness for certification. The reviewing
DBHR Certification Specialist will determine if the extent of the deficiencies must be corrected
prior to certification or as a part of a corrective action process following approval.

Section I – CURRENT PROVIDER INFORMATION

1.     For private providers, enter the entity or firm name listed on your Washington State
       Master Business License. Public providers must indicate the name of the tribal, federal,
       state, county, or municipal government, health district, or educational service district
       under which the agency will operates.

2.     Enter your Federal Employer Tax Identification Number (FEIN), if you have one, or your
       social security number (if sole proprietor).

3.     Enter your nine-digit Uniform Business Identification Number (UBI), found on your
       Master Business License.

Section II – CURRENT AGENCY INFORMATION

1.     Enter the current certified agency name, as it is listed in the Directory of State Certified
       Chemical Dependency Treatment Services in Washington State (Directory). The
       Directory can be found at http://www.dshs.wa.gov/dbhr/dadirectory.shtml.

2.     Use the second line to print additional organizational titles, if any. Both lines appear in
       the Directory.

3.     Enter the eight digit agency number in the boxes provided. If you are unsure of the
       agency number, it can be found with your agency listing in the Directory.

Section III – TYPE OF OWNERSHIP CHANGE

Check the box that applies.

Section IV – NEW OWNER INFORMATION

1.     Indicate whether or not you will use the current agency name.

2.     If changing the agency name, enter the new agency name, as you want it listed in the
       Directory.

3.     Use the second line to print additional organizational titles, if any. Both lines will appear
       in the Directory.


                                      Instructions - Page 2 of 4
      Example:

         Addiction Recovery Services (1st line)
         ABC Medical Center (2nd line)

         Or,

         ABC Medical Center (1st line)
         Addiction Recovery Services (2nd line)

4.    Enter the Federal Employer Tax Identification Number (FEIN) for the new agency, if you
      have one, or your social security number (if sole proprietor).

5.    Enter the nine-digit Uniform Business Identification Number (UBI), found on your new
      agency’s Master Business License.

6.    Check the type of organization for the new agency.

Section V – FACILITY INFORMATION

1.    Ensure the correct location address is correct. Make sure it contains all of the
      necessary information such as “NW,” “Street,” “Way,” etc. so directions can be found
      online.

2.    If the mailing address is different than the physical location, ensure that it is indicated by
      checking the box.

3.    List the new agency telephone numbers even if they are the same as the current
      agency.

4.    DBHR maintains a list of administrator and agency e-mail addresses as well as the
      agency web site address. Please provide them if you have them.

Section VI – CHEMICAL DEPENDENCY SERVICES FOR WHICH NEW OWNER IS
APPLYING

1.    Check the box for each service you will be providing.

2.    Using the Funding Source Codes, enter the funding source for each service checked.

3.    Enter the number of beds for each residential service. Check your Department of
      Health Residential Treatment License for total number of beds. If also providing mental
      health or detoxification services, enter only the number of beds allocated for the
      chemical dependency services.

4.    Enter the treatment focus, if any. Examples of treatment focus are “Faith-based,”
      “Youth,” “Spanish-Speaking,” etc. Unless left blank, this will be published in the
      Directory.

Section VII – NEW PROVIDER APPLICATION MATERIALS TO BE SUBMITTED




                                    Instructions - Page 3 of 4
1.     Enter the name, title, mailing address, and telephone number of the person who
       represents the Governing Body. This may be the President of the Board of Directors,
       the Chief Executive Officer, or the agency Administrator. For a Sole Proprietor, the Sole
       Proprietor is the Governing Body, so just write in “Sole Proprietor.”

2.     If the new owner is privately operated, check each box in the appropriate section and
       ensure that each item is included with the application.

3.     Include a copy of the transfer/sales agreement between the outgoing owner and the
       incoming owner, as required by WAC 388-805-105(2)(d).

4.     Include a copy of the letter to the county Alcohol and Drug Coordinator. Be sure to
       attach a copy of the application. If you need the mailing address for the County Alcohol
       and Drug coordinator, it can be found in Appendix A of the Directory

5.     Even though not required by WAC, DBHR asks that, at least for the application, that the
       organizational chart includes the staff person’s name, as well as title and number of
       FTE’s for each position.

6.     In Section VII.E, please ensure that each question, items 1-10 is answered completely,
       and that all required attachments are included with the application.

Section VIII – APPLICANT DECLARATIONS

Ensure that both the representatives of the current provider’s governing body and the new
owner’s governing body carefully read and sign the Declaration.

Section IX – APPLICANT CONTACT INFORMAT

If the applicant contact information is the same as the governing body’s legal representative,
check the appropriate box. I different, enter the contact information.


(f:\shared\certific\new forms\provider requests/ Ownership Change revised 11/9/11)




                                    Instructions - Page 4 of 4

				
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