The Virginia Provider Application form is a crucial document required for organizations seeking to establish and operate behavioral health services in Virginia. This form must be completed by an authorized individual, such as a chief executive officer or director, who is responsible for the organization's compliance with state regulations. It collects essential information about the applicant, including organizational structure, service types, and management details, to ensure that standards are met for the provision of care.
The Virginia Provider Application form is a crucial document for organizations seeking to provide behavioral health and developmental services in the state. This form requires detailed information about the applicant, including the organization’s name, mailing address, and contact details. It also mandates disclosure of ownership percentages, ensuring transparency in governance. The application must be completed by a responsible individual, such as a chief executive officer or director, who oversees the service operations. Applicants must specify their organizational structure, whether they are a non-profit, for-profit, or governmental agency, and indicate any relevant accreditations. Additionally, the form collects essential details about the parent company, if applicable, and the specific type of service the organization intends to provide. This includes various mental health and substance abuse services tailored for children and adolescents. Furthermore, the application outlines the necessity for supporting documents, such as a working budget and evidence of financial resources, to demonstrate the organization’s capability to operate effectively. Completing this application accurately and thoroughly is vital for compliance with Virginia's licensing regulations.
Virginia Department of Behavioral Health & Developmental Services
INITIAL PROVIDER APPLICATION FOR LICENSING
Code of Virginia §37.2-405 & §35-46
Please use a typewriter or print legibly using permanent, black ink. The chief executive officer, director, or other member of the governing body who has the authority and responsibility for maintaining standards, policies, and procedures for the service may complete this application.
1.APPLICANT INFORMATION: Identify the person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service:
Organization Name:_____________________________________________________________________________________
Mailing Address________________________________________________________________________________________
City:__________________________ County __________________________________State:___________________________
Zip:___________________ Phone:( )___________________________ Email:_________________________________
Names of all Owners and the percentage (%) of the organization owned by each _____________________________________
___________________________________________________________________________________________________________
Chief Executive Officer or Director. Identify the person responsible for the overall management and oversight of the service(s) to be operated by the applicant.
Name:____________________________________________Title:_______________________________________________
Phone:( )___________________ Fax Number:( )___________________ E-mail:____________________________
All Residential Services: (The liaison is the staff that shall be responsible for facilitating cooperative relationship with neighbors, the school system, local law enforcement, local government officials and the community at large.)
Community Liaison Name: _________________________ Phone ( )_______________ E-mail _____________________
2.ORGANIZATIONAL STRUCTURE: Identify the organizational structure of the applicant’s governing body.
Check one(1) of the following:
[] Non-Profit
[] For-Profit
[] Individual (proprietorship)
[] Partnership
[] Corporation
[] Unincorporated Organization or Association
Public agency:
[] State [] Community Services Board
[] Other _________________________________
Identify accrediting or certifying organization from the following, if applicable:
[] Accreditation Council for Services for People with Developmental Disabilities
[] Virginia Association of Special Education Facilities
[] Joint Commission on Accreditation of Health Care Organizations
[] Other associations or organizations:
[] Commission on Accreditation of Rehabilitation Facilities
_________________________________________
3.APPLICANT PARENT COMPANY INFORMATION: Identify the parent company of person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service:
Company
Name:_______________________________________________________________________________________________
Mailing Address:______________________ _____City:_____________ County: _____________________ State:_____________
Zip:___________ Phone:( )__________________________ E-mail:_______________________________________________
Name:___________________________________________________Title:_______________________________________
SERVICE TYPE:
Place a check to identify the service type. If the service type is not listed, please note in the service information section. Please note new applicants (no independent service operation experience) are permitted to apply for ONE service on the initial application.
Check
one
Service
Pgm
Description
Licensed As Statement
A Level C mental health children's residential service for children with serious
14
001
Level C MH Children Residential Service
emotional disturbance
A mental health children's residential service for children with serious emotional
004
MH Children Residential Service
disturbance
007
SA Children Residential Service
A substance abuse children's residential service for children
A mental health group home residential service for children with serious emotional
008
MH Children Group Home Residential Service
033
SA Children Group Home Residential Service
A substance abuse group home residential service for children
035
DD Children Group Home Residential Service
A developmental disability group home residential service for children
An intermediate care facility for individuals with a developmental disability (ICF-IDD)
048
ICF-IDD Children Group Home Residential Service
group home residential service for children
A residential group home with crisis stabilization REACH service for children and
adolescents with a co-occurring diagnosis of developmental disability and behavioral
59
REACH Children’s Residential Service
health needs
10/6/17 DBHDS
5.SERVICE INFORMATION: Complete for the organization to be licensed by the Department of Behavioral Health and Developmental Services.
Service Director: __________________________________________________________________________________
Phone: (
) ________________________________________ E-
Mail_____________________________________
Client Demographics (check all that apply):
[] Male
[] Female [] Both
[] Child
[] Adolescent (Min. & Max. Age Range) _____________ [] Adult
LOCATION
6.Location Name__________________________________________# of beds:_______________________________
Address:___________________________________________________________________________________________
City:_____________________ County: _____________________ State:________________ Zip:___________________
Location Manager:________________________________ Phone:( )______________ E-
mail:____________________
Directions:_________________________________________________________________________________________
7. NAME AND ADDRESS OF OWNER OF PHYSICAL PLANT
Name
Address
8. RECORDS: IDENTIFY THE LOCATION OF THE FOLLOWING RECORDS
Financial Records
Address: ________________________________________City:___________________ County ___________________
State:________________ Zip:____________
Personnel Records
Residents’ Records
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REQUIRED ATTACHMENTS
Children’s Residential Service
All Other Services
Regulations
1.
The Completed Application form
§12 VAC 35-46-20 (D)(1)
§35-105-40(A)
2.
A Working Budget (appropriated revenues and projected
§35-105-40(A)(1)
expenses for one year –a 12-month period)
§12 VAC 35-46-190 (A)(2)
3.
Evidence of financial resources or line of credit sufficient to
§12 VAC 35-46-180
§35-105-210(A) &
cover estimated operating expenses for ninety days (and must be
§35-105-40(A)(2)
maintained on an ongoing basis)
4.
A copy of the Organizational Structure, showing the
§35-105-190(B)
relationship of the management and leadership to the service
& §12 VAC 35-46-20 A
5.
Complete Service Description (including philosophy and
§35-105-40 & §580(C),
objectives of the organization, comprehensive description of population
§570
to be served, admission, exclusion, continued stay,
discharge/termination criteria, a description of services or interventions
to be offered, brochures, pamphlets distributed to the public, a copy of
the proposed program schedule, etc)
6. Record Management Policy addressing all the requirements of
§12 VAC 35-46-20 B [1-5]
§35-105-40 & §870(A),
the regulation
§12 VAC 35-46-180. C
390
7.
Staffing Schedule & Written Staffing plan (use staff
§35-105-590
information sheet to list potential staff members with designated
positions & qualifications, etc.), relief staffing plan, & comprehensive
supervision plan
8.
Resumes of all identified Staff, particularly services director,
§12 VAC 35-46-270 (B)(1)
§35-105-420(A)
QIDP, QMHP, and licensed personnel.
9.
Position Descriptions- copies of all position(job) descriptions
§35-105-40 & §410(A)
that address all the requirements (position descriptions for case
§12 VAC 35-46-280,
management, ICT and PACT services must address the additional
§12 VAC 35-46-340 &
regulations for those services).
§12 VAC 35-46-350
10. Evidence of Authority to conduct Business in Virginia.
§35-105-40(A)(3) and
Generally this will a copy of the applicant’s State Corporation
& §12 VAC 35-46-320
§190(B)
Commission Certificate.
11. Certificate of Occupancy – for the building where services are
§35-105-260
to be provided (except home-based services),
AND FOR RESIDENTIAL SERVICES:
Copy of the Building floor plan, with dimensions
§35-105-40 (B)(5)
13. Current Health Inspection
§12 VAC 35-46-20 B
§35-105-290
14. Current Fire Inspection
§12 VAC 35-46-20 (D)[1-4]
§35-105-320
Children’s Residential Service Only
15. Articles of Incorporation, By- laws, & Certificate of
Facility operated by a
Incorporation
VA corporation
16 Articles of Incorporation, By- laws, & Certificate of Authority
out of state corporation
6. . Listing of board members, the Executive Committee, or public
§12 VAC 35-46-20-170
Facilities with a
agency all members of legally accountable governing body
Governing Board
References for three officers of the Board including President,
§12 VAC 35-46-20 D
Facility operated by
Secretary and Member-at-Large
Corp., an
unincorporated
Organization, or an
Association
4
Current/Past Provider Services
Please identify:
1)The legal names and dates of any services licensed in Virginia or other states that the applicant currently holds or has held,
2)Previous sanctions or negative actions against any licensed to provide services that the holds or has held in any other state or in Virginia, and
3)The names and dates of any disciplinary actions involving the applicant’s current or past licensed services. If none, please indicate, “NONE” in the space below.
Current Services:
_____________________________________________________________________________________________
Past Services:
Sanctions/Negative Actions/Disciplinary Actions:
Certificate of Application
This certificate is to be read and signed by the applicant. The person signing below must be the individual applicant in the case of a proprietorship or partnership, or the chairperson or equivalent officer in the case of a corporation or other association, or the person charged with the administration of the service provided by the appointing authority in the case of a governmental agency.
I am in receipt of and have read the applicable rules and regulations for licensing. It is my intent to comply with the statutes and regulations and to remain in compliance if licensed.
I grant permission to authorized agents of the Department of Behavioral Health and Developmental Services to make necessary investigations into this application or complaints received.
I understand that unannounced visits will be made to determine continued compliance with regulations.
TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL INFORMATION CONTAINED HEREIN IS CORRECT AND COMPLETE. I FURTHER DECLARE MY AUTHORITY AND RESPONSIBILITY TO MAKE THIS APPLICATION.
Signature of Applicant:_______________________________________Title:______________________
Date:_________________
If you have any questions concerning the application, please contact this office at (804) 786-1747. Please return the completed application to:
Office of Licensing
Department of Behavioral Health and Developmental Services
Post Office Box 1797
Richmond, Virginia 23218-1797
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