Form 220 "Notification Form for Closing or Moving a Behavioral Health Agency Site" - Arkansas

What Is Form 220?

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;
  • 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 220 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 220 "Notification Form for Closing or Moving a Behavioral Health Agency Site" - Arkansas

305 times
Rate (4.7 / 5) 21 votes
ARKANSAS DEPARTMENT OF HUMAN SERVICES
NOTIFICATION FORM FOR CLOSING OR MOVING
A BEHAVIORAL HEALTH AGENCY SITE
Moving a site constitutes a closing of one site and a move of the program(s), move of existing staff and move of
existing client base to another location. If a provider relocates a currently certified site within a fifty (50) mile radius
the accrediting agency, DHS and Medicaid must be notified thirty (30) days prior to that relocation. Neither an on-
site survey nor a new Medicaid number is required in order to extend certification to the moved location if within a
fifty (50) miles radius.
Name of Agency:
Chief Executive Officer (or equivalent):
Corporate Compliance Officer (or equivalent):
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
This is notification that the following site(s) is/are:
________ moving
______closing
CLOSING Date of Closure: ______________________
Site Closing Address:
Street Address
City
State
Zip
MOVING Date of Move: ________________________
Previous Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
New Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
DHS Behavioral Health Agency Site Move or Close – Form 220
Effective July 1, 2017
Page 1 of 2
ARKANSAS DEPARTMENT OF HUMAN SERVICES
NOTIFICATION FORM FOR CLOSING OR MOVING
A BEHAVIORAL HEALTH AGENCY SITE
Moving a site constitutes a closing of one site and a move of the program(s), move of existing staff and move of
existing client base to another location. If a provider relocates a currently certified site within a fifty (50) mile radius
the accrediting agency, DHS and Medicaid must be notified thirty (30) days prior to that relocation. Neither an on-
site survey nor a new Medicaid number is required in order to extend certification to the moved location if within a
fifty (50) miles radius.
Name of Agency:
Chief Executive Officer (or equivalent):
Corporate Compliance Officer (or equivalent):
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
This is notification that the following site(s) is/are:
________ moving
______closing
CLOSING Date of Closure: ______________________
Site Closing Address:
Street Address
City
State
Zip
MOVING Date of Move: ________________________
Previous Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
New Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
DHS Behavioral Health Agency Site Move or Close – Form 220
Effective July 1, 2017
Page 1 of 2
Please attach all documentation to and from your accrediting organization regarding the above
information. Certification will not be granted to the new site address until all information from the
accrediting organization indicates that the new site address is accredited.
Chief Executive Officer (or equivalent) Certification: By my signature, 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
Notification Form for Closing/Moving
1. In addition to this form, please provide any information that is specific to the site/s for which
certification is being requested that is different from those agency sites already certified by DHS.
2. Include a photograph of outside entrance to building, staff offices, and waiting area for all new
site locations.
Please send this form with required documentation 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 Behavioral Health Agency Site Move or Close – Form 220
Effective July 1, 2017
Page 2 of 2
Page of 2