Form 310 "Application for Partial Hospitalization Certification" - Arkansas

What Is Form 310?

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:

  • The latest edition provided by the Arkansas Department of Human Services;
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  • Fill out the form in our online filing application.

Download a printable version of Form 310 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 310 "Application for Partial Hospitalization Certification" - Arkansas

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ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR PARTIAL HOSPITALIZATION CERTIFICATION
To be completed upon initial application to become certified as a Partial Hospitalization Program
Name of Agency:
Chief Executive Officer (or equivalent):
Corporate Compliance Officer (or equivalent):
Administrative Address:
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
Website:
The provider named above shall be certified by the Department of Human Services as a
Behavioral Health Agency. A Partial Hospitalization certification will not be issued if the
provider is not a part of a DHS certified Behavioral Health Agency. A Certified Behavioral
Health Agency can submit one (1) application for multiple Partial Hospitalization sites, with the
Personnel Resources to be completed for each site.
Behavioral Health Agency Certification Period:
through
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all
information contained in this form and in all attachments is correct and complete.
Signature of Chief Executive Officer (or equivalent)
Date
Name of Chief Executive Officer (or equivalent) typed or printed
DHS Partial Hospitalization Certification – Form 310
Effective: July 1, 2017
Page 1 of 3
ARKANSAS DEPARTMENT OF HUMAN SERVICES
APPLICATION FOR PARTIAL HOSPITALIZATION CERTIFICATION
To be completed upon initial application to become certified as a Partial Hospitalization Program
Name of Agency:
Chief Executive Officer (or equivalent):
Corporate Compliance Officer (or equivalent):
Administrative Address:
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
Website:
The provider named above shall be certified by the Department of Human Services as a
Behavioral Health Agency. A Partial Hospitalization certification will not be issued if the
provider is not a part of a DHS certified Behavioral Health Agency. A Certified Behavioral
Health Agency can submit one (1) application for multiple Partial Hospitalization sites, with the
Personnel Resources to be completed for each site.
Behavioral Health Agency Certification Period:
through
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all
information contained in this form and in all attachments is correct and complete.
Signature of Chief Executive Officer (or equivalent)
Date
Name of Chief Executive Officer (or equivalent) typed or printed
DHS Partial Hospitalization Certification – Form 310
Effective: July 1, 2017
Page 1 of 3
Required Documentation
All of the following information must be attached to the Partial Hospitalization Certification.
Applications not submitted in full will not be processed.
1. Valid Behavioral Health Agency Certification from the Department of Human Services.
2. Physical Address of all requested Partial Hospitalization sites. An on-site inspection will
occur at all sites prior to DHS issuing a certification as a Partial Hospitalization program.
3. Personnel Resources for each Partial Hospitalization program to be certified, see page 3.
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 a Partial
Hospitalization program 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 Partial Hospitalization Certification – Form 310
Effective: July 1, 2017
Page 2 of 3
PERSONNEL RESOURCES FOR EACH INDIVIDUAL
PARTIAL HOSPTIALIZATION PROGARM
(as of the date this is submitted)
Site Address:
Partial Hospitalization Program Facility Director:
1. Psychiatrists
2. M.D. Non-psychiatrists
3. Psychologists
4. Independently Licensed Clinicians
5. Non-independently Licensed Clinicians
6. Registered Nurses
7. Qualified Behavioral Health Providers (Including Certified Peer
Support Specialist, Certified Youth Support Specialist, Certified
Family Support Partners)
8. All other staff not included above
9. Sum of lines 1-8
DHS Partial Hospitalization Certification – Form 310
Effective: July 1, 2017
Page 3 of 3
Page of 3