Form 100 "Application for Behavioral Health Agency Certification" - Arkansas

What Is Form 100?

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;

Download a printable version of Form 100 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

ADVERTISEMENT
ADVERTISEMENT

Download Form 100 "Application for Behavioral Health Agency Certification" - Arkansas

268 times
Rate (4.8 / 5) 16 votes
Arkansas Department of Human Services
Application for Behavioral Health Agency Certification
To be completed upon initial application to become certified as a Behavioral Health Agency
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 is fully accredited and in good standing with one of the following
accreditation organizations. (Please check your accreditation organization)
____
The Joint Commission (TJC)
____
Commission on Accreditation for Rehabilitation Facilities (CARF)
____
Council on Accreditation (COA)
Date(s) of most recent survey:
Accreditation Period:
The accredited provider is located within the State of Arkansas.
______ Yes
______ No
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 Behavioral Health Agency Application for Certification – Form 100
Effective: July1, 2017
Page 1 of 2
Arkansas Department of Human Services
Application for Behavioral Health Agency Certification
To be completed upon initial application to become certified as a Behavioral Health Agency
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 is fully accredited and in good standing with one of the following
accreditation organizations. (Please check your accreditation organization)
____
The Joint Commission (TJC)
____
Commission on Accreditation for Rehabilitation Facilities (CARF)
____
Council on Accreditation (COA)
Date(s) of most recent survey:
Accreditation Period:
The accredited provider is located within the State of Arkansas.
______ Yes
______ No
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 Behavioral Health Agency Application for Certification – Form 100
Effective: July1, 2017
Page 1 of 2
Required Documentation
All of the following information must be attached to the Behavioral Health Agency Certification.
Applications not submitted in their entirety will not be processed. Incomplete applications will
be returned to the applicant without review.
1. Latest accreditation survey results. (The entire survey report covering outpatient
behavioral health services must be included.)
2. 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.
3. A signed agreement that DHS may receive information directly from the accrediting
organization regarding the agency’s accreditation and any information pertaining to
service delivery. (See DHS BEHAVIORAL HEALTH AGENCY Form 200)
4. All Evidence of Compliance, Measures of Success, Performance Improvement Plans, and
any Corrective Action Plans submitted to the accreditation organization pertaining to
outpatient behavioral health services.
5. Behavioral Health Agency Services and Resource Summary Report with all attachments
as designated in the Behavioral Health Agency Services and Resource Summary Form
(DHS BEHAVIORAL HEALTH AGENCY Form 210).
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 Behavioral
Health Agency 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 Application for Certification – Form 100
Effective: July1, 2017
Page 2 of 2
Page of 2