Becoming an ADAD-licensed treatment agency is a privilege and a

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Becoming an ADAD-licensed treatment agency is a privilege and a Powered By Docstoc
					DBH USE ONLY Check# Amount

DIVISION OF BEHAVIORAL HEALTH SUBSTANCE USE DISORDER TREATMENT LICENSE APPLICATION Application Must Be Typed or Legibly Written in Ink

DBH USE ONLY TFM Date

LICENSING INFORMATION
Application Date License Application Type:
1

Medicaid Clinic Number (if Medicaid provider) Initial License Unlicensed License Renewal Three-Year License1 Provisional License Expiration Date
Moved Closed

License Modification Probationary License

Application for a Three-Year License is required for agencies completing Provisional or Probationary License periods.

Current License Status: License # (if licensed)

Three-Year License Date Effective

AGENCY MAIN SITE CONTACT INFORMATION Agency Zip TDD/TTY County E-mail Street Phone Director

City Fax

Program Name (if different) Director (if different) Instructions for Initial License, License Renewal, and Three-Year License Applications (1) Enter all applicable Licensing Information and mark the “Initial License,” “License Renewal,” or “Three-Year License” box, as appropriate. (2) Enter all Agency Main Site Contact Information. (3) Enter Agency Governance Information (below). (4) Provide documentation appropriate to license application type (Pages 2 and 3). (5) Enter Treatment Site Information, if applicable (instructions on Page 3). (6) Sign Attestation (Page 6). Instructions for Updating Agency Main Site Contact Information (License Modification Application) (1) Enter applicable Licensing Information and mark the “License Modification” and “Update” boxes. (2) Enter Agency Main Site Contact Information and indicate changes by marking the box to the left of each updated item. (3) Mark the “Moved” box if updates include a change of address; mark the “Closed” box if the agency is closing or is being sold. (4) Provide applicable License Modification Documentation (Page 3). (5) If changes to Agency Main Site Contact Information are the only modifications, it is not necessary to complete the remainder of the License Modification application except to (6) sign the Attestation (Page 6). To update Treatment Site Information, see Page 3. AGENCY GOVERNANCE INFORMATION Profit Corporation
2

Non-profit Corporation

Partnership2

Sole Proprietor2

Unit of Government

As of January 1, 2007, pursuant to H.B. 06S-1009, C.R.S. 24-34-107, only persons lawfully present in the United States will be issued a license. Therefore, all Sole Proprietor or Partnership applicants for original licensure or licensees renewing a current Colorado license after January 1, 2007 are required to complete and sign an Affidavit of Eligibility, and may also be required to provide valid identification when requested.

Officers, Partners, Sole Proprietor, Unit of Government

Current Address

Instructions for Initial License, License Renewal and Three-Year License Applications (1) Mark the box to the left of the type of governance under which the agency operates. (2) Enter the names and addresses of all officers, partners, a sole proprietor, or a representative of a unit of government, as appropriate. (3) For an Initial or Renewal License application, provide documentation of agency governance (see respective Required Documentation on page 2). Instructions for Updating Agency Governance Information (License Modification Application) (1) Enter applicable Licensing Information, mark the “License Modification” box, and enter Agency Main Site Contact Information (Page 1). (2) Mark the “Update” box to the left of “Agency Governance Information” (above). (3) Enter all governance information, including updated items. (4) If agency governance is being changed, provide documentation of new agency governance as required by Initial License Documentation (Page 2). If changes in Agency Governance Information are the only modifications it is not necessary to complete the remainder of the application except to (5) sign the Attestation (Page 6). Page 1 of 8
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REQUIRED DOCUMENTATION Initial License Documentation  Description of applicant agency including: treatment philosophy; client populations served; geographic area(s) of operation; evidenced-based or best practice treatment services provided; and methods used to engage and retain clients in treatment.  Applicant’s knowledge of and experience in the treatment of substance use disorders and agency administration. Documentation may include resumes, certificates, licenses, transcripts, etc.  Up-to-date agency organization charts showing lines of authority, including names of clinical personnel and their credentials, positions and job responsibilities.  Documentation that counselors are specifically trained or otherwise qualified by education and experience to treat the clients the agency serves. Documentation may include academic transcripts, CAC certificates, professional licenses, resumes, job applications, job descriptions, etc.  Documentation that background investigations have been performed on all agency staff. At a minimum, verification must include copies of name check reports from the Colorado Bureau of Investigation at 303-239-4300 or at cbi@state.co.us and TRAILS Check reports from the CDHS Background Investigation Unit, Records and Reports Section, at 3550 W. Oxford, 3rd Floor, Denver, CO or at 303-866-7183.  Written documentation from client referral sources that proposed treatment services are relevant to community needs.  Written agency operating policies and procedures that are based on and in compliance with DBH Substance Use Disorder Treatment Rules.  Documentation of agency governance, including: copies of articles of incorporation and corporate by-laws for profit and nonprofit corporations; documentation of 501(c) 3 status for non-profit corporations; formal partnership agreements for partnerships; trade name affidavits for sole proprietors; documentation of governmental status for units of government.  A complete and signed Affidavit of Eligibility is required for Sole Proprietorship and Partnership agencies, pursuant to H.B. 06S-1009, C.R.S. 24-34-107 (pages 7 and 8 of this application).  Copies of declaration pages from property liability insurance, current and in force. For agencies renting business sites, copies of property liability insurance held by property owner or manager will suffice.  Copies of declaration pages from agency or individual professional liability insurance, current and in force.  Copies of up-to-date fire inspection reports. For agencies renting business sites, copies of most recent fire inspection reports from property owner or manager will suffice.  Copies of up-to-date health inspection reports for residential sites and/or sites where food is prepared.  Written evidence of compliance with local zoning ordinances. License Renewal Documentation  Up-to-date agency organization charts showing lines of authority, including names of clinical personnel and their credentials, positions and job responsibilities.  Operating policies and procedures revised during license period.  Copies of declaration pages from property liability insurance; current and in force.  Copies of declaration pages from agency or individual professional liability insurance; current and in force.  Copies of up-to-date fire inspection reports.  Copies of up-to-date health inspection reports for residential sites and/or sites where food is prepared.  Documentation of compliance with local zoning ordinances from local planning/zoning office.  A complete and signed Affidavit of Eligibility is required for Sole Proprietorship and Partnership agencies, pursuant to H.B. 06S-1009, C.R.S. 24-34-107 (pages 7 and 8 of this application). Three-Year License Documentation  Detailed description of the steps taken by the agency to carry out all provisions or corrective actions required by the Provisional or Probationary License.  Copies of supporting documentation such as: policies and procedures; client record forms; agency organizational charts and staffing patterns; staff credentials; counselor supervision records; insurance declaration pages; service delivery protocols; etc. License Modification Documentation  When Adding or Moving Treatment Sites: Copies of site-specific property liability insurance declaration pages; copies of sitespecific fire inspection reports; copies of health inspection reports for residential sites and/or sites where food is prepared; and documentation of compliance with local zoning ordinances. Page 2 of 8
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 When Adding Services or Modalities: Copies of policies and procedures specific to each added service and/or modality; documentation that counselors are specifically trained or otherwise qualified by education and experience to provide each additional service in each additional modality.  When Selling or Closing Agencies or Treatment Sites or Discontinuing Services/Modalities: Written plan for carrying out applicable DBH rules and policies, including notification of referral sources and clients. TREATMENT SITE INFORMATION INSTRUCTIONS The following instructions are for completing the Treatment Site Information forms on Pages 4 and 5. Note: It is required that written policies and procedures specific to each service and modality for which a license is requested be submitted with Initial License applications. Treatment Site Information Instructions For Initial License And License Renewal Applications

 

Enter Treatment Site Contact Information. For Initial License applications, do not enter Site # and DRS #. Mark the box to the left of each Treatment Service provided. If the agency is required to implement Emergency Commitments because it receives public funds to provide detox services, or if it is privately funded to provide detox services and wishes to implement Emergency Commitments, mark the “Emergency Commitments” box to the right of “Medical Detox” or “Nonhospital Residential Detox,” as appropriate. “General Treatment Services” means substance use disorder treatment services that are not tailored to specific client populations. Mark the box to the left of each Treatment Modality in which each Treatment Service is located. Medical Detox and Non-hospital Residential Detox are considered to be both services and modalities. Enter information on all Clinical Personnel working on-site. In the “Modality” column, use the Treatment Modality Abbreviations found at the bottom of Pages 4 and 5. “Hours” means the number of hours of clinical supervision each counselor receives per month. Refer to 6 CCR 1008-3, Addiction Counselor Certification and Licensure Standards, for a definition of clinical supervision and the number of supervision hours per month required for each level of counselor certification or license. This document is available from the Department of Regulatory Agencies, 1560 Broadway, Suite 1370, Denver, CO 80202, 303-8947800. If the current Provisional or Probationary License affects the entire agency, it is not necessary to enter Treatment Site Information. If the license affects Treatment Services or Modalities at individual treatment sites, enter up-to-date Treatment Site Contact Information for those sites and mark only the Treatment Services and Modalities that are affected by the license. Do not mark the “Update,” “Added,” “Moved,” or “Closed” boxes. Enter applicable Licensing Information and all Agency Main Site Contact Information (Page 1). If the treatment site is newly acquired, mark the “Update” and “Added” boxes and enter Treatment Site Contact Information (except for Site # and DRS #) and Treatment Services, Modalities, and Clinical Personnel information. Provide applicable License Modification Documentation (Page 3). To update Treatment Site Contact Information, mark the “Update” box, enter all Treatment Site Contact Information, and indicate changes by marking the box to the left of each updated item. Mark the “Moved” box if updates include a change of address; mark the “Closed” box if the treatment site is closing or is being sold. Provide applicable License Modification Documentation (Page 3). If changes to Treatment Site Contact Information are the only modifications, it is not necessary to complete the remainder of the form. If Treatment Services or Modalities have been added or discontinued, mark the “Update” box, enter Treatment Site Contact Information, and mark the box to the left of each added and discontinued Treatment Service and Modality with an “A” (added), or a “D” (discontinued), as appropriate. Provide applicable License Modification Documentation (Page 3). Note: It is required that written policies and procedures specific to each added service and modality be submitted with License Modification applications. Sign the Attestation (Page 6).

 

Treatment Site Information Instructions For Three-Year License Application

 

Instructions For Updating Treatment Site Information (License Modification Application)

  





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To record additional sites, copy this page. To list additional counselors, use plain paper and the Clinical Personnel format. TREATMENT SITE INFORMATION Treatment Site Contact Information Site# Zip Code E-mail Treatment Services Offender Education and Treatment Level I DUI Education Level II DUI Education Level II DUI Treatment Opioid Replacement Treatment Medical Detox Emergency Commitments Minors’ Treatment Involuntary Commitments Non-hospital Res. Detox Emergency Commitments Gender-Specific Women’s Treatment Child Welfare Client Treatment General Treatment Services Counselor Credentials Modality OP OP OP OP OP MDX OP OP RDX OP OP OP Clinical Personnel # Cases Clinical Supervisor Credentials Hours EOP DRS# Street County Site Administrator Treatment Modalities IOP DAY TRT IRT TC Phone City Fax Phone Added Moved Closed

EOP

IOP

DAY

TRT

IRT

TC

IOP IOP IOP IOP IOP

DAY DAY DAY DAY DAY

TRT TRT TRT TRT TRT

IRT IRT IRT IRT IRT

TC

TC TC TC

TREATMENT SITE INFORMATION Treatment Site Contact Information Site# Zip Code E-mail Treatment Services Offender Education and Treatment Level I DUI Education Level II DUI Education Level II DUI Treatment Opioid Replacement Treatment Medical Detox Emergency Commitments Minors’ Treatment Involuntary Commitments Non-hospital Res. Detox Emergency Commitments Gender-Specific Women’s Treatment Child Welfare Client Treatment General Treatment Services Counselor Credentials Modality OP OP OP OP OP MDX OP OP RDX OP OP OP Clinical Personnel # Cases EOP DRS# Street County Site Administrator Phone

Added City

Moved

Closed

Fax Phone

Treatment Modalities IOP DAY TRT IRT TC

EOP

IOP

DAY

TRT

IRT

TC

IOP IOP IOP IOP IOP

DAY DAY DAY DAY DAY

TRT TRT TRT TRT TRT

IRT IRT IRT IRT IRT

TC

TC TC TC Hours

Clinical Supervisor

Credentials

Treatment Modality Abbreviations Key: MDX = Medical Detoxification; RDX = Non-hospital Residential Detoxification; OP = Outpatient Treatment; EOP = Enhanced Outpatient Treatment; IOP = Intensive Outpatient Treatment; DAY = Day Treatment; TRT = Transitional Residential Treatment; IRT = Intensive Residential Treatment; TC = Therapeutic Community

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To record additional sites, copy this page. To list additional counselors, use plain paper and the Clinical Personnel format. TREATMENT SITE INFORMATION Treatment Site Contact Information Site# Zip Code E-mail Treatment Services Offender Education and Treatment Level I DUI Education Level II DUI Education Level II DUI Treatment Opioid Replacement Treatment Medical Detox Emergency Commitments Minors’ Treatment Involuntary Commitments Non-hospital Res. Detox Emergency Commitments Gender-Specific Women’s Treatment Child Welfare Client Treatment General Treatment Services Counselor Credentials Modality OP OP OP OP OP MDX OP OP RDX OP OP OP Clinical Personnel # Cases Clinical Supervisor Credentials Hours EOP DRS# Street County Site Administrator Treatment Modalities IOP DAY TRT IRT TC Phone City Fax Phone Added Moved Closed

EOP

IOP

DAY

TRT

IRT

TC

IOP IOP IOP IOP IOP

DAY DAY DAY DAY DAY

TRT TRT TRT TRT TRT

IRT IRT IRT IRT IRT

TC

TC TC TC

TREATMENT SITE INFORMATION Treatment Site Contact Information Site# Zip Code E-mail Treatment Services Offender Education and Treatment Level I DUI Education Level II DUI Education Level II DUI Treatment Opioid Replacement Treatment Medical Detox Emergency Commitments Minors’ Treatment Involuntary Commitments Non-hospital Res. Detox Emergency Commitments Gender-Specific Women’s Treatment Child Welfare Client Treatment General Treatment Services Counselor Credentials Modality OP OP OP OP OP MDX OP OP RDX OP OP OP Clinical Personnel # Cases EOP DRS# Street County Site Administrator Phone

Added City

Moved

Closed

Fax Phone

Treatment Modalities IOP DAY TRT IRT TC

EOP

IOP

DAY

TRT

IRT

TC

IOP IOP IOP IOP IOP

DAY DAY DAY DAY DAY

TRT TRT TRT TRT TRT

IRT IRT IRT IRT IRT

TC

TC TC TC Hours

Clinical Supervisor

Credentials

Treatment Modality Abbreviations Key: MDX = Medical Detoxification; RDX = Non-hospital Residential Detoxification; OP = Outpatient Treatment; EOP = Enhanced Outpatient Treatment; IOP = Intensive Outpatient Treatment; DAY = Day Treatment; TRT = Transitional Residential Treatment; IRT = Intensive Residential Treatment; TC = Therapeutic Community

Page 5 of 8
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ATTESTATION

I attest by my signature that this license application, documentation included with this application, and documentation located at the administrative offices and treatment sites of the applicant is truthful and accurate. I understand that deliberate falsification of the application, documentation included with the application and documentation located at the administrative offices and treatment sites will result in denial of this application and may also result in prosecution for perjury in the second degree as defined by Colorado Revised Statutes Title 18, Article 8, Part 5. I also understand that failing to submit accurate data to DBH in a timely fashion, including Drug/Alcohol Coordinated Data System (DACODS) reports and Discharge Referral Summary (DRS) reports, may result in denial of this application.

Signature

Print Name

Date

The person whose signature appears on the Attestation must be responsible for agency governance, such as a corporate officer, business partner, sole proprietor, or representative of a unit of government.

IMPORTANT LICENSING INFORMATION

 Failure to submit a completed Initial License application, including required written documentation and license fee (government
agencies excepted) may delay or terminate the licensing process.

 A License Renewal application received by DBH on or before the license expiration date will allow the applicant's current license
to remain in effect until DBH acts on the License Renewal application.

 A License Renewal application received by DBH after the license expiration date shall be returned to the applicant with written
notice that the applicant's DBH license is no longer in effect and that the applicant must re-apply for an Initial License and include all required documentation.

 When a treatment site has been added to an agency or has been moved to another location and a License Modification application
has not been submitted to DBH, the site shall not be considered to be DBH-licensed.

 Hours of education and/or treatment provided by a treatment site that is not DBH-licensed, or whose DBH license is no longer in
effect, may not count toward fulfilling clients' obligations to agencies such as courts, probation, parole, the Motor Vehicle Division, or other referral sources that require their clients to attend DBH-licensed agencies.  Licensed treatment agencies and Initial License applicants are strongly encouraged to take advantage of DBH’s on-line communication services, including e-mail contact and electronic transmission of client data, by equipping themselves with appropriate computer hardware and software to access the Internet.

 Licensing decisions may be appealed in accordance with the State Administrative Procedures Act.
INSTRUCTIONS FOR SUBMITTING LICENSE APPLICATION

Submit the following    Original application; Copies of written documentation (do not send originals); $200 license fee (make checks or money orders payable to DBH). An application fee is not required for government agencies, License Modification applications, or for reapplication following a Provisional License.

Mail to: Division of Behavioral Health (DBH), Attn: Licensing Desk, 3824 W. Princeton Circle, Denver, CO 80236

Page 6 of 8
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Affidavit Of Eligibility
Pursuant to H.B. 06S-1009, C.R.S. 24-34-107, all Sole Proprietorship and Partnership applicants for original licensure or licensees renewing a current Colorado license after January 1, 2007 are required to complete and sign this Affidavit of Eligibility. Section A: LAWFUL PRESENCE in the United States. I, (please print your full name) of perjury under the laws of the State of Colorado that (check 1, 2 or 3 below): 1. 2. I am a US citizen. I am not a US citizen but am lawfully present in the US as evidenced by one of the following: a. b. c. 3. I am a qualified alien as defined in 8 U.S.C. sec 1641. I am a nonimmigrant under the "Immigration and Nationality Act", Federal Public Law 82-414 as amended. I am an alien who is paroled into the US under 8 U.S.C. sec. 1182 (d) (5). , swear or affirm under penalty

I am not physically present in the US under 8 U.S.C. sec 1621 (c) (2) (c) or employed in the US pursuant to 8 U.S.C. 1621 (c) (2) (a) (check either a or b below) a. b. I am a US citizen, not physically present or employed in the United States. I am a Foreign National, not physically present or employed in the United States. If you selected either 3.a. or 3.b., you do not need to complete Section B. Skip to Section C.

Section B: Secure and Verifiable Document. This section must be completed if you checked number 1 or 2 in Section A. 1. Please check one of the following acceptable secure and verifiable documents. Complete documentation must be provided upon request only. Any Colorado Driver License, Colorado Driver Permit or Colorado Identification Card, expired less than one year. (Temporary paper license with invalid Colorado Driver License, Colorado Driver Permit, or Colorado Identification Card, expired less than one year is considered acceptable. Out-of-state issued photo Driver License or photo Identification Card, photo Driver Permit expired less than one year. Valid foreign passport bearing an unexpired “Processed for I-551” stamp or with an attached unexpired “Temporary I551” visa. Valid I-551 Resident Alien or Permanent Resident card. Valid foreign passport accompanied by an “I-94” indicating a specific future “until” date. Valid 1-94 issued by Canadian government with L1 or R1 status and a valid Canadian Driver License or valid Canadian Identification Card. Valid Temporary Resident Card. Valid I-94 with refugee/asylum stamp. Valid 1688B and 1766 Employment Authorization Card. Valid US Military ID (active duty, dependent, retired, reserve and National Guard). Tribal Identification Card with intact photo (US or Canadian). Certificate of Naturalization with intact photo. Certificate of (US) Citizenship with intact photo. Passport issued by the U.S. Government with one of the following documents: Social Security Card; marriage, divorce or separation certificate or decree; or a Colorado or Federal tax return. Colorado Department of Corrections Inmate Identification Card with a Social Security Card issued by the United States Government.

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Affidavit Of Eligibility, continued 2. Enter the state or the federal agency name where this secure and verifiable document was issued.
(If issued by a state agency, include both the state and agency name.)

3. What is the secure and verifiable document number? 4. What is the expiration date of your secure and verifiable document (month/day/year)?
(If you hold a document without an expiration date, such as a military ID or naturalization certificate, write N/A.)

Section C: Attestation.  I understand that this sworn statement is required by law because I have applied for or hold a professional or commercial license regulated by 8 U.S.C. sec 1621. I understand that State law requires me to provide proof that I am lawfully present in the United States when asked as well as submission of a secure and verifiable document. I may also be required to provide proof of lawful presence. I understand that in accordance with sections 18-8-503 and 18-8-501(2)(a)(I), C.R.S., false statements made herein are punishable by law. I state under penalty of perjury in the second degree, as defined in 18-8-503, C.R.S. that the above statements are true and correct. I am the person identified above and the information contained herein is true and correct to the best of my knowledge. I understand that under Colorado law, providing false information is grounds for denial, suspension or revocation of a license, certificate, registration or permit. I understand that the above information must be disclosed to the Colorado Department of Human Services (CDHS) upon request and is subject to verification.







_________________________________________________ Signature Date

Please print your name as shown on your secure and verifiable document. DBH License Number (if already licensed):

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