Form 500 "Application for an Independently Licensed Practitioner" - Arkansas

What Is Form 500?

This is a legal form that was released by the Arkansas Department of Human Services - a government authority operating within Arkansas. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2017;
  • The latest edition provided by the Arkansas Department of Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form 500 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form 500 "Application for an Independently Licensed Practitioner" - Arkansas

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ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR AN INDEPENDENTLY LICENSED PRACTITONER
To be completed upon initial application to become certified as an Individually Licensed Practitioner
Name:
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
Website:
Description of outpatient behavioral health services provided:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Days of Operation:
Business Hours:__________________________
Description of how and by whom clients are covered 24 hours a day/7 days a week, addressing crisis
services as well as routing services delivery:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you provide medication management through your facility? ______ Yes
______ No
If not, how is medication management handled for your clients?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Description of How you will collaborate with other agencies/individuals to facility quality and continuity
of care for clients:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of Chief Executive Officer (or equivalent)
Date
Name of Chief Executive Officer (or equivalent) typed or printed
DHS Independently Licensed Practitioner Certification – Form 500
Effective July 1, 2017
Page 1 of 2
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR AN INDEPENDENTLY LICENSED PRACTITONER
To be completed upon initial application to become certified as an Individually Licensed Practitioner
Name:
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
Website:
Description of outpatient behavioral health services provided:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Days of Operation:
Business Hours:__________________________
Description of how and by whom clients are covered 24 hours a day/7 days a week, addressing crisis
services as well as routing services delivery:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Do you provide medication management through your facility? ______ Yes
______ No
If not, how is medication management handled for your clients?
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Description of How you will collaborate with other agencies/individuals to facility quality and continuity
of care for clients:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
Signature of Chief Executive Officer (or equivalent)
Date
Name of Chief Executive Officer (or equivalent) typed or printed
DHS Independently Licensed Practitioner Certification – Form 500
Effective July 1, 2017
Page 1 of 2
Required Documentation
All of the following information must be attached to the Independently Licensed Practitioner
Certification. Applications not submitted in full will not be processed.
1. Names, credentials and relevant experiences for backup and medication management
physicians.
2. Names, credentials and relevant experience of applicant’s experience providing behavioral
health services.
3. Copies of any affiliation agreements with other agencies/professionals that provide
behavioral health services for your clients.
4. Copies of pertinent certifications and/or licenses (i.e. JCAHO, CARF, staff licensure or
certification by State boards to practice behavioral health services, etc.). Applicant MUST
submit Arkansas licensure which grants the applicant that authority to engage in
private/independent practice by the appropriate State Board.
5. Copies of any forms used for documentation (treatment plan, psychosocial history, etc.)
6. Copies of all correspondence and e-mails (e-mails may be copied to the DHS) between the
agency and the accrediting organization that pertains to the accreditation of the provider’s
outpatient behavioral health services.
DHS WILL REVIEW THIS APPLICATION WITHIN NINETY (90) CALENDAR DAYS OF
RECEIPT.
DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR
DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
Please send a cover letter and all application materials to be certified by DHS as an
Independently Licensed Practitioner to the following address:
Arkansas Department of Human Services
Division of Provider Services and Quality Assurance
ATTN: Barbra Brooks
P.O. Box 8059, Slot S408
Little Rock, AR 72203
DHS Independently Licensed Practitioner Certification – Form 500
Effective July 1, 2017
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