ࡱ>  e 5bjbj 4xj\xj\e- bb8,*dt 1111,HMOHqqqqqqquxNq PG^,HPPqbb11sUUUP^b811qUPqUU6kXn1`__DLQrlqs0tlxRx8XnXn&x~n0PPUPPPPPqqUPPPtPPPPxPPPPPPPPP > (:    IMPORTANT: PLEASE READ INSTRUCTIONS BEFORE COMPLETING APPLICATION  This application packet should be used by applicants/programs that are seeking licensure under COMAR Title 10, Subtitle 63 Community-Based Behavioral Health Programs and Services. Before applying for licensure under COMAR 10.63, a program shall enter into an agreement to cooperate with the core service agency (CSA), local addictions authority (LAA), or local behavioral health authority (LBHA) for each jurisdiction in which the program proposes to operate. A copy of the agreement(s), signed by the appropriate CSA, LAA, or LBHA, must accompany this application. The CSA, LAA, or LBHA will need a copy of page 2, all applicable pages 3-4 of this application, and proof of accreditation, if applicable, as part of the process of signing the agreement. For a copy of the Agreement to Cooperate, please go to  HYPERLINK "http://bha.dhmh.maryland.gov/Pages/Forms.aspx" http://bha.dhmh.maryland.gov/Pages/Forms.aspx. This is a fillable document, which means that you may complete it electronically. You must then print it out, sign where indicated and appropriate, and then submit it along with all required supplemental materials. Please fill in the requested information completely. If this application is incomplete or missing any of the documentation required, the processing of the application will stop and the application will be returned to the applicant to provide the missing information (COMAR 10.63.06.02B). Please note that Section 3 of the application is required for each program site (except for residential rehabilitation program sites with three or fewer beds). All complete applications are reviewed in the order that they are received. This is the most equitable way to prioritize the application review process. Due to the number of applications received, there may be a wait period before your application can be reviewed. We do appreciate your understanding. Please read and familiarize yourself with the most current regulation chapters - COMAR 10.63 Community-Based Behavioral Health Programs and Services. If you need a copy of the regulations, please contact the Division of State Documents at (410) 974-2486 or Toll Free at (800) 633-9657, or go to the following web address to download the order form:  HYPERLINK "http://www.dsd.state.md.us/PDF/DHMHBooklets.pdf" http://www.dsd.state.md.us/PDF/DHMHBooklets.pdf. When completing the form to request COMAR booklets, return that form and payment to: Office of the Secretary of State Division of State Documents State House Annapolis, MD 21401 Tel: 410-260-3876 800-633-9657 Fax: 410-280-5647. If you want to review the regulations on-line, please go to:  HYPERLINK "http://www.dsd.state.md.us/COMAR/ComarHome.html" http://www.dsd.state.md.us/COMAR/ComarHome.html and follow the instructions. Please Return Completed Application to: Stacey Diehl, Program Manager Office of Licensing Behavioral Health Administration Spring Grove Hospital Center Voc Rehab Building 55 Wade Avenue Catonsville, MD 21228 Should you have any questions about this application form, please contact the Behavioral Health Licensing Unit at (410) 402.8198.  1) PROVIDER INFORMATION: The corporate/business name of the provider/program must match what is registered with the Maryland Department of Assessments and Taxation (SDAT). If something doesnt apply to you, mark NA. If NA is marked, you may be asked to provide a reason the section doesnt apply to you, if the reason is not obvious. Corporate/Business Name:  FORMTEXT      Corporate Address (City, State, Zip):  FORMTEXT      County:  FORMTEXT      Corporate Website:  FORMTEXT      Trade Name (if different from Corporate Name):  FORMTEXT      Website (if different from Corporate Website): Owner Last Name:  FORMTEXT      First Name:  FORMTEXT      Primary Contact:  FORMTEXT      Phone: ( FORMTEXT      )  FORMTEXT      - FORMTEXT      Title:  FORMTEXT      Primary Contact Email:  FORMTEXT       @  FORMTEXT      Fax: ( FORMTEXT      )  FORMTEXT       -  FORMTEXT        2) CORRESPONDENCE ADDRESS INFORMATION: In the event that correspondence must be sent via the United States Postal Service, enter the Correspondence Address to which you want all your correspondence mailed. Please note that, when possible, communications will be sent via email.  FORMCHECKBOX  Corporate Name/Address  FORMCHECKBOX  Other: Street Address:  FORMTEXT       City:  FORMTEXT       State:  FORMTEXT       Zip:  FORMTEXT        3) APPLICATION TYPE: Please check all program and/or service types that apply. Program/service types marked with an (*) do not require accreditation in order to receive a license for that particular program/service type (COMAR 10.63.05.03). All other program/service types require accreditation in order to receive a license (COMAR 10.63.02.02). Capacity means the total number of individuals that a program can accommodate. This section must be completed for each physical site, except for residential rehabilitation program sites with three or fewer beds. Program Address:  FORMTEXT Insert Street AddressCounty/Baltimore City:  FORMTEXT        FORMTEXT Insert City, State, ZipCapacity# Beds# Adults# Adolescentss# Children FORMCHECKBOX  DUI Education Program (COMAR 10.63.05.05)* FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Early Intervention Level 0.5 Program (COMAR 10.63.05.06)* FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Group Homes for Adults with Mental Illness (COMAR 10.63.04.03) FORMTEXT        FORMCHECKBOX  Integrated Behavioral Health Program (COMAR 10.63.03.02) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Intensive Outpatient Treatment Level 2.1 Program (COMAR 10.63.03.03) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Mobile Treatment Services Program (MTS) (COMAR 10.63.03.04) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Opioid Treatment Services (COMAR 10.63.03.19) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Outpatient Mental Health Center (OMHC) (COMAR 10.63.03.05) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Outpatient Treatment Level 1 Program (COMAR 10.63.03.06) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Partial Hospitalization Treatment Level 2.5 Program (COMAR 10.63.03.07) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Psychiatric Day Treatment Program (PDTP) (COMAR 10.63.03.08) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Psychiatric Rehabilitation Program for Adults (PRP-A) (COMAR 10.63.03.09) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Psychiatric Rehabilitation Program for Minors (PRP-M) (COMAR 10.63.03.10) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Residential Crisis Services Program (RCS) (COMAR 10.63.04.04) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       3) Application Type: Continued Capacity# Beds# Adults# Adolescents# Children FORMCHECKBOX  Residential- Low Intensity Level 3.1 Program (COMAR 10.63.03.11) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Residential- Medium Intensity Level 3.3 Program (COMAR 10.63.03.12)  FORMTEXT       FORMTEXT       FORMCHECKBOX  Residential-High Intensity Level 3.5 Program (COMAR 10.63.03.13) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Residential-Intensive Inpatient Level 3.7 Program (COMAR 10.63.03.14)(Requires Certificate of Need) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Residential Rehabilitation Program (RRP) (COMAR 10.63.04.05) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Respite Care Services Program (RPCS) (COMAR 10.63.03.15) FORMTEXT       FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Substance-Related Disorder Assessment and Referral Program (COMAR 10.63.05.14)* FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Supported Employment Program (SEP) (COMAR 10.63.03.16) FORMTEXT       FORMTEXT       FORMTEXT       FORMCHECKBOX  Withdrawal Management Service (COMAR 10.63.03.18) FORMTEXT       FORMTEXT       FORMTEXT        4) ATTESTATION THAT PROGRAM COMPLIES WITH SPECIFIC PROGRAM & SERVICE DESCRIPTION(S). I,  FORMTEXT Insert Name am affirming that  FORMTEXT Insert Corporate/Business Name is in compliance and will remain in compliance with all applicable regulations, including any and all program/service descriptions, specific staffing requirements and appropriate staff credentials as they relate to the program(s)/service(s) identified in Section 3 of this application. _________________________________________ __________________ (Signature) (Date)  5) ATTESTATION OF COMPLIANCE WITH RELEVANT FEDERAL, STATE, OR LOCAL ORDINANCES, LAWS, REGULATIONS, AND ORDERS GOVERNING THE PROGRAM. I,  FORMTEXT Insert Name, am affirming that  FORMTEXT Insert Corporate/Business Name shall comply with all applicable federal, state and local ordinances, laws, regulations, transmittals, guidelines, orders, administrative service organization provider alerts and provider manual instructions governing the program. _________________________________________ __________________ (Signature) (Date)  6) ATTESTATION OF COMPLIANCE WITH COMAR 10.01.18, SEXUAL ABUSE AWARENESS AND PREVENTION TRAINING (required for publicly-funded psychiatric rehabilitation programs for adults and minors, residential rehabilitation programs, and supported employment programs.) I,  FORMTEXT Insert Name, am affirming that  FORMTEXT Insert Corporate/Business Name shall comply with COMAR 10.01.18, Sexual Abuse Awareness and Prevention Training. _________________________________________ __________________ (Signature) (Date)  7) ATTESTATION(S) FOR SPECIFIC PROGRAM STAFF. Please check all relevant staff positions listed below. Staff who hold the specific position must sign the affidavit. (For agencies with multiple sites, additional signature lines are provided for instances in which more than one individual functions in the role and when each individual meets all the regulatory requirements that are listed.) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  FORMCHECKBOX  Outpatient Mental Health Center (OMHC) (COMAR 10.63.03.05C) An OMHC shall employ a medical director, who: (1) Is a psychiatrist (attach copy of applicable credential); (2) Has over-all responsibility for clinical services; and (3) Is on-site at least 20 hours per week. Affidavit: Under the penalties of perjury, acknowledge that I am the medical director of  FORMTEXT Insert Corporate/Business Name. I specifically acknowledge that I am a psychiatrist, have overall responsibility for clinical services, and am on-site at the OMHC at least 20 hours per week.  FORMTEXT Insert Name, M.D., Maryland License Number  FORMTEXT Insert License #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D., Maryland License Number  FORMTEXT Insert License #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D., Maryland License Number  FORMTEXT Insert License #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D., Maryland License Number  FORMTEXT Insert License #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D., Maryland License Number  FORMTEXT Insert License #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  FORMCHECKBOX  Psychiatric Rehabilitation Program for Adults (PRP-A) (COMAR 10.63.03.09C&D) A PRP-A shall be under the direction of a rehabilitation specialist who is: A licensed mental health professional; certified by the Commission on Rehabilitation; Counselor Certification; or certified by the Psychiatric Rehabilitation Association (attach copy of applicable credential); and Employed at least 20 hours per week when the program serves less than 30 individuals; or 40 hours per week when the program serves 30 individuals or more. Affidavit: Under the penalties of perjury, acknowledge that I am the rehabilitation specialist for  FORMTEXT Insert Program Name PRP-A, which serves  FORMTEXT Insert # number of individuals per week. I specifically acknowledge that I have overall responsibility for the direction of rehabilitation services, and am employed at the PRP-A for the amount of time required according to the provisions of COMAR 10.63.03.09D.  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  FORMCHECKBOX  Psychiatric Rehabilitation Program for Minors (PRP-M) (COMAR 10.63.03.10B&C) A PRP-M shall be under the direction of a rehabilitation specialist who: Has a minimum of 2 years direct care experience working with youth with a serious emotional disorder; Is a licensed mental health professional; or certified by the Psychiatric Rehabilitation Association and has obtained the Psychiatric Rehabilitation Association Childrens Psychiatric Rehabilitation Certificate (attach copy of applicable credential); and Is employed at least 20 hours per week when the program serves less than 30 individuals or at least 40 hours per week when the program serves 30 individuals or more. Affidavit: Under the penalties of perjury, acknowledge that I am the rehabilitation specialist for  FORMTEXT Insert Program Name PRP-M, which serves  FORMTEXT Insert # number of individuals per week. I specifically acknowledge that I have a minimum of 2 years direct care experience working with youth with a serious emotional disorder; have overall responsibility for the direction of rehabilitation services, and am employed at the PRP-M for the amount of time required according to the provisions of COMAR 10.63.03.10C .  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, effective  FORMTEXT Insert Date, employed  FORMTEXT Insert # Hours hours per week _________________________________________ __________________ (Signature) (Date) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%  FORMCHECKBOX  Opioid Treatment Service (COMAR 10.63.03.19) The opioid treatment service is one that is under the direction of a medical director who is a physician and: 1. Has at least 3 years of documented experience providing services to persons with substance-related disorders and opioid use disorders, including at least 1 year of experience in the treatment of opioid use disorder with opioid maintenance therapy and is board-certified in addiction medicine or addiction psychiatry (attach copy of applicable credential) ; or 2. Is certified in added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc. (attach copy of applicable credential). Affidavit: Under the penalties of perjury, acknowledge that I am the medical director of  FORMTEXT Insert Program Name opioid treatment service. I specifically acknowledge that I am board-certified in addiction medicine, addiction psychiatry, or certified in added qualifications in addiction psychiatry by the American Board of Psychiatry and Neurology, Inc.  FORMTEXT Insert Name, M.D. (print), Maryland License Number  FORMTEXT Insert #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D. (print), Maryland License Number  FORMTEXT Insert #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D. (print), Maryland License Number  FORMTEXT Insert #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D. (print), Maryland License Number  FORMTEXT Insert #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  FORMTEXT Insert Name, M.D. (print), Maryland License Number  FORMTEXT Insert #, effective  FORMTEXT Insert Date _________________________________________ __________________ (Signature) (Date)  8) REQUIRED DISCLOSURES (check all that apply and provide all documentation supporting or demonstrating the information disclosed): YES NO (check one for each of the following)  FORMCHECKBOX   FORMCHECKBOX  Has there been a revocation of a license, certificate, or approval issued within the previous 10 years from any in-State or out-of-State provider previously or currently associated with the applicant;  FORMCHECKBOX   FORMCHECKBOX     NOP " 4    5 8 f  F | òzslhlalals h1~(h bhk h1~(h,i h1~(hA h1~(h^| h1~(hh h1~(h h1~(h h1~(h w h1~(hGa h1~(hC| h856 jh856UmHnHuh\h856CJaJhW jhQbEhUmHnHuhh8h25jh^(UmHnHu$   NP E dgd8 dgdm dgdC| dgd\ dgd0 dgd $da$gd8 dgdW| } ~ u v 6j OXYxqfqfjh1~(h_9U h1~(h_9h1~(h85 h1~(h8 h1~(hM h1~(hGah1~(h5h1~(hE96 h1~(hE9 h1~(hj2 h1~(hPt h1~(h  h1~(hFd h1~(hm h1~(hC| hw"2h1~(h1~(h0h1~(hT"0Jjh1~(hT"U h1~(hT"%Ywy%&'CDE/01ǿ޳޳ޯިދ޳޳qjah X5CJaJ h rhE9 jh rhE9UmHnHuh1~(h8^Jh1~(h8B*phh1~(h\^Jh1~(h0^J h1~(h0hQhh1~(h8>*h1~(hGa>* h1~(hGah1~(hGa5h1~(h85 h1~(h8 h1~(h_9jh1~(h_9Uh1~(h_90J%EF01zd$Ifgd{>C dgd@R dgdGa dgdE9d^`gd0 dgd8 dgdm [bcRThjlvx|ǼxcZOh4h CJaJh 5CJaJ(jh\h :CJUaJmHnHu#juh\h :CJUaJh\h :CJaJjh\h :CJUaJh\h :5CJaJh\h@R5CJaJh\h@RCJaJh\hA CJaJh\h\CJaJh\h0CJaJh\hE9CJaJh\hE95CJaJz|(d$Ifgd{>Cikd$$Ifl      * +  t0       +44 laytlyn$&(*>NRTh岡wk_kPEh\hGaCJaJjh\hGaCJUaJh4hGa5CJaJh\hGa5CJaJ+jh\h@R5CJUaJmHnHu&jh\h@R5CJUaJ jh\h@R5CJUaJh\h@R5CJaJ(jh\h@RCJUaJmHnHu#jph\h@RCJUaJh\h@RCJaJjh\h@RCJUaJ(*zud$Ifgd |kd^$$Ifl      0F*Z t0       +44 layt{>Chjlvx|^lnp޾r]QFQh1~(hCJaJhh5CJaJ(jh\hCJUaJmHnHu#jh\hCJUaJh\hCJaJjh\hCJUaJhhCJaJh5CJaJh\h5CJaJh\hGaCJaJ(jh\hGaCJUaJmHnHujh\hGaCJUaJ#jh\hGaCJUaJz|ikdH$$Ifl      * + t0       +44 layt dLd$IfgdGaikdY$$Ifl      * + t0       +44 layt dLnpzld$Ifgd{>Cd$IfgdPtikd$$Ifl      * + t0       +44 layt dLd$IfgdGap"$8:<FHJVZ\p٠ٔzhSzzz(jh\hGaCJUaJmHnHu#jh\hGaCJUaJh\hGaCJaJjh\hGaCJUaJh\hGa5CJaJ#jh\hX0CJUaJ(jh\hX0CJUaJmHnHu#j6h\hX0CJUaJh\hX0CJaJjh\hX0CJUaJh\hX05CJaJJ uggd$Ifgd{>Cd$IfgdGa|kd"$$Ifl      0 *v t0       +44 laytX0prt~ <>RTV`bhj~޾޾޾޾޾޾|޾޾j޾޾#jh\hGaCJUaJ#jh\hGaCJUaJh\hGa5CJaJ#j h\hGaCJUaJ#jh\hGaCJUaJh\hGaCJaJ(jh\hGaCJUaJmHnHujh\hGaCJUaJ#jh\hGaCJUaJ&  pbTd$Ifgd{>Cd$IfgdGakd$$Ifl      F :*v0 f t0       +    44 laytX0~   "޾޾޾޾޾޾|޾q\Qh\hE9CJaJ(j_h\hE9CJUaJmHnHuh\h@RCJaJ#jbh\hGaCJUaJ#jh\hGaCJUaJ#jth\hGaCJUaJh\hGa5CJaJh\hGaCJaJ(jh\hGaCJUaJmHnHujh\hGaCJUaJ#jh\hGaCJUaJ"$yyyyyrrdZ dgdz d`gdDIgdDI dgdE9|kd$$Ifl      0 *v t0       +44 laytX0 "$t /8 ԎobSA#jh\hE9CJUaJjh\hE9CJUaJhDICJ\]^JaJ-jh\h. 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jh\hBx5CJUaJh5CJaJh\h4&CJaJh\hbCJaJ&jfh\h4&5CJUaJh\h4&5CJaJ jh\h4&5CJUaJ Has the applicant, a program, corporation or provider previously or currently associated with the applicant, surrendered or defaulted on its license, certificate, or approval for reasons related to disciplinary action, within the previous 10 years;  FORMCHECKBOX   FORMCHECKBOX  Has any individual who has served as a corporate officer for the provider who has had a license, certificate, or approval revoked, or has surrendered or defaulted on an approval, license, certificate, or approval, for reasons related to disciplinary action, within the previous 10 years. If check, please provide the name of that individual:  FORMTEXT Insert Name Affidavit: I,  FORMTEXT Insert Name, am affirming that the above statements are true. _________________________________________ __________________ (Signature) (Date)  9) ACCREDITATION INFORMATION: If you are applying for an accreditation-based license under COMAR Title 10, Subtitle 63, please check the appropriate accreditation organization. You must provide a copy of the most recent behavioral health accreditation survey report, a copy of any corrective action plans required by the behavioral health accreditation organization survey report of the program, and a copy of the final letter or certificate issuing accreditation for the program. PLEASE NOTE: Applicants currently on an extension from an accreditation organization are not eligible to apply under COMAR 10.63 until the accreditation has been formally renewed and there are begin and end effective dates.  FORMCHECKBOX  Accreditation Commission for Health Care (ACHC)  Effective Dates: From  FORMTEXT       To  FORMTEXT        FORMCHECKBOX  Council on Accreditation (COA)  Effective Dates: From  FORMTEXT       To  FORMTEXT        FORMCHECKBOX  Council on Accreditation of Rehabilitation Facilities (CARF)  Effective Dates: From  FORMTEXT       To  FORMTEXT        FORMCHECKBOX  The Joint Commission (TJC)  Effective Dates: From  FORMTEXT       To  FORMTEXT        10) REQUIRED SUPPLEMENTAL INFORMATION/DOCUMENTS. Please submit with this application, a copy of the following documents and answer any additional questions. If any required document is missing, this application will not be processed and will be returned to the applicant. FOR ALL APPLICANTS:  FORMCHECKBOX  Copy of the signed Agreement to Cooperate between the program and the CSA, LAA, or LBHA, for each jurisdiction (County/Baltimore City) in which the program proposes to operate. (Please note, the BHA Licensing Unit is not responsible for obtaining the signature from the CSA, LAA or LBHA that is the responsibility of the applicant);  FORMCHECKBOX  Copies of the:  FORMCHECKBOX  Fire Inspection Report/Permit  FORMCHECKBOX  Use and Occupancy Permit (if applicable)  FORMCHECKBOX  Copy of the programs policy on criminal background investigation (COMAR 10.63.01.05C)  FORMCHECKBOX  Copy of all documentation supporting or demonstrating the information disclosed under Section 8 of this Application  FORMCHECKBOX  Copy of documented proof of the programs good standing status with SDAT %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% FOR ACCREDITATION-BASED LICENSE APPLICANTS:  FORMCHECKBOX  Copy of the most recent behavioral health accreditation survey report, if applying for an accreditation- based license;  FORMCHECKBOX  Copy of any corrective action plans required by the behavioral health accreditation organization survey report of the program; and  FORMCHECKBOX  Copy of the final letter or certificate issuing accreditation for the program. %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% FOR RESIDENTIAL REHABILITATION PROGRAMS:  FORMCHECKBOX  Copy of the CSA or LBHA (whichever is appropriate) annual site inspection report/certificate (COMAR 10.63.04.05J)  FORMCHECKBOX  Total number of Beds:  FORMTEXT Insert #  FORMCHECKBOX  Copy of the program s policy regarding the managed intervention plan (COMAR 10.63.04.05K) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% FOR RESIDENTIAL-INTENSIVE INPATIENT LEVEL 3.7 PROGRAMS:  FORMCHECKBOX  Copy of Certificate of Need (CON) %%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%%% FOR NON-ACCREDITATION BASED LICENSE APPLICANTS: :;IJKM8˚͚̚ךؚٚļļ㭢ugWJ?h\h5CJaJhi5CJ]^JaJh5h55CJ]^JaJh\h;5>*CJaJh5h4&CJaJh\hiCJaJmHnHu#j2ih\hiCJUaJh\hiCJaJjh\hiCJUaJh5CJaJh\h4&CJaJ&jhh\h4&5CJUaJh\h4&5CJaJ jh\h4&5CJUaJEd{pdXOC80hSKoCJaJh\hSKoCJaJh\hSKo5CJaJhSKo5CJaJhzhSKo5CJaJhzhe o5CJaJh\h4&CJaJ(j>jh\h4&CJUaJmHnHu h\hih\hi5CJ\]^Jh\hi5CJ]^Jh\hiCJOJQJ]^Jh\hiCJaJmHnHujh\hiCJUaJ#jih\hiCJUaJh\hiCJaJE̞Ξޟʠ֢آڢܢޢgd gdzgdSKo dgdSKo dgd4&#gd;gd5!`gd5Ȟ̞ΞОXxʟ̟Ο؟ڟܟޟFftvݼݰݞΉwΉo]ݰ#jMph\hSKoCJUaJhSKoCJaJ#joh\hSKoCJUaJ(jh\hSKoCJUaJmHnHu#jaoh\hSKoCJUaJhqhSKo5CJaJ#jnh\hSKoCJUaJjh\hSKoCJUaJh\hSKoCJaJhzhSKoCJaJhhSKo5CJaJ"ƠȠʠ̠¡ʡ̡R޾޾ޤ޾޾޾޾޾n޾޾\޾#jsh\hSKoCJUaJ#jrh\hSKoCJUaJ#j%rh\hSKoCJUaJ#jqh\hSKoCJUaJhSKoCJaJ#j9qh\hSKoCJUaJh\hSKoCJaJ(jh\hSKoCJUaJmHnHujh\hSKoCJUaJ#jph\hSKoCJUaJ$RrĢƢȢҢԢ֢آܢޢٲٲ蘐pdXLhzh4&5CJaJhzhe o5CJaJhzh:k5CJaJ(jsth\hSKoCJUaJmHnHuh\hCJaJhCJaJhSKoCJaJ#jsh\hSKoCJUaJ(jh\hSKoCJUaJmHnHu#jsh\hSKoCJUaJjh\hSKoCJUaJh\hSKoCJaJhqhSKo5CJaJ.Bңԣ ɤͤΤ֤3IܵܖxmbZObhhzCJaJhzCJaJhhhhCJaJh hiCJaJh=h4&CJaJh=hiCJaJhhCJaJh h4&CJaJ&j yh\h4&5CJUaJ jh\h4&5CJUaJh5hOCJaJh\hOCJaJh\h4&CJaJh5hwe5CJaJh\h4&5CJaJIT\]^p   -./1NOP^_`ϼ|qq]qI&jzh\h4&5CJUaJ&j zh\h4&5CJUaJh\h4&CJaJ&jyh\h4&5CJUaJh\h4&5CJaJ jh\h4&5CJUaJhzh4&B*CJaJphhzh4&CJaJhCJaJhzh=CJaJh=CJaJhhhhCJaJhhCJaJhzhhCJaJOq   . dgd r dgdDI dgd4& !dh`gd dgdgJ_gd `gdh`btzgh~maMmaB:he oCJaJh\h;CJaJ&jn{h\h;5CJUaJh\h;5CJaJ jh\h;5CJUaJheQh 6CJaJheQhJ6CJaJh\hJCJaJ&jzh\hJ5CJUaJh\hJ5CJaJ jh\hJ5CJUaJhzhgJ_CJaJhzh4&CJaJh\h4&CJaJh\h4&5CJaJhoyzǧbɽɽ{n{bQb=&j\|h\h4&5CJUaJ jh\h4&5CJUaJh\h4&5CJaJh5CJOJQJ]^Jh\hCJOJQJ]^Jh;CJaJh\hCJaJh\h0CJaJ&j{h\h05CJUaJh\h05CJaJ jh\h05CJUaJhzCJaJhzh/CJaJhe oCJaJhzhe oCJaJʩ̩   _  bдؘ|o|cXh\hA"CJaJh\hJ5CJaJh5CJOJQJ]^Jh\hCJOJQJ]^Jh\hDI5CJaJh4&CJaJ&jH}h\h4&5CJUaJh5CJaJ&j|h\h4&5CJUaJhDICJaJh\h4&CJaJh\h4&5CJaJ jh\h4&5CJUaJ"  (.0>.0LNPİ~l~]R@]#j~h\hiCJUaJh\hiCJaJjh\hiCJUaJ#j4~h\h3DCJUaJh\h3DCJaJjh\h3DCJUaJheQh 6CJaJheQh r6CJaJhDICJaJh\h3D5CJaJh\h rCJaJ&j}h\h r5CJUaJh\h r5CJaJ jh\h r5CJUaJήЮҮ`bn*,ƻƻyi\iPD5jh\h;CJUaJh\h2 t5CJaJh\h;5CJaJhDICJOJQJ]^Jh\hCJOJQJ]^JhqCJOJQJ]^Jh\h2 tCJaJheQh 6CJaJheQhJ6CJaJ#j2h\hJCJUaJh\hJCJaJjh\hJCJUaJh\h3DCJaJjh\hiCJUaJh\hiCJaJmHnHu., PQ@A dgd/ !dh`gd/ dgd; !dh`gd d`gd rgd  l;OPQĴ|h|]QHh/>*CJaJh/h/6CJaJh/h/CJaJ&j h/h/5CJUaJ jh/h/5CJUaJh/h/>*CJaJUh/h/5CJaJh/CJOJQJ]^Jh\h/CJOJQJ]^Jh/CJaJh;CJaJjh\h;CJUaJ#jh\h;CJUaJh\h;CJaJ  FORMCHECKBOX  Copy of the programs grievance policy (COMAR 10.63.05.07C)  FORMCHECKBOX  Copy of the programs DUI Curriculum, if providing DUI education services (COMAR 10.63.05.05) Is your facility ready for an on-site inspection at the time of application?  FORMCHECKBOX  Yes  FORMCHECKBOX  No If you answered No, what is the anticipated date that site will be ready for inspection:  FORMTEXT Insert Date NOTE: Should not be more than 6 months from date of application submission. Hours of OperationMondayTuesdayWednesdayThursdayFridaySaturdaySunday FORMTEXT       to  FORMTEXT       FORMTEXT       to  FORMTEXT       FORMTEXT       to  FORMTEXT       FORMTEXT       to  FORMTEXT       FORMTEXT       to  FORMTEXT       FORMTEXT       to  FORMTEXT       FORMTEXT       to  FORMTEXT        11) AUTHORIZATION: I,  FORMTEXT Insert Name, the practitioner, administrator or authorized professional representative of this group, hereby affirm that this information given by me is true and complete to the best of my knowledge and belief. 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