Form 240 "Behavioral Health Agency Annual Reporting Form" - Arkansas

What Is Form 240?

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 240 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 240 "Behavioral Health Agency Annual Reporting Form" - Arkansas

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Arkansas Department of Human Services
Behavioral Health Agency Annual Reporting Form
State Fiscal Year
: 07/01/20
through 06/30/20
Name of Agency:
Chief Executive Officer (or equivalent):
Corporate Compliance Officer (or equivalent):
Clinical Director (or equivalent):
Medical Director (or equivalent):
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
Provider Type:
Private Non-Profit
Private for Profit
Public Entity
Other (Specify):
Chief Executive Officer (or equivalent) Certification: By my signature, I certify that I have
reviewed this report and attachments and to the best of my knowledge it represents an accurate
report of agency services and resources.
Signature of Chief Executive Officer (or equivalent)
Date
Name of Chief Executive Officer (or equivalent) typed or printed
DHS Behavioral Health Agency Annual Report – Form 240
Effective July 1, 2017
Page 1 of 4
Arkansas Department of Human Services
Behavioral Health Agency Annual Reporting Form
State Fiscal Year
: 07/01/20
through 06/30/20
Name of Agency:
Chief Executive Officer (or equivalent):
Corporate Compliance Officer (or equivalent):
Clinical Director (or equivalent):
Medical Director (or equivalent):
Physical Address:
Street Address
City
State
Zip
Mailing Address:
Street Address
City
State
Zip
County:
Phone:
Fax:
E-mail:
Provider Type:
Private Non-Profit
Private for Profit
Public Entity
Other (Specify):
Chief Executive Officer (or equivalent) Certification: By my signature, I certify that I have
reviewed this report and attachments and to the best of my knowledge it represents an accurate
report of agency services and resources.
Signature of Chief Executive Officer (or equivalent)
Date
Name of Chief Executive Officer (or equivalent) typed or printed
DHS Behavioral Health Agency Annual Report – Form 240
Effective July 1, 2017
Page 1 of 4
THIS REPORT RELATES TO AGENCY WIDE INFORMATION
1. Please include all annual reporting requirements from the accrediting organization.
This includes Annual Conformance to Quality Report, Maintenance of Accreditation or Intra-
Cycle Monitoring Profile. Please include all correspondence to and from the accrediting
organization related to annual reporting requirements.
2. Provider’s plans and activities to overcome cultural and linguistic barriers to
treatment. Include a brief statement regarding on-going efforts to serve clients from diverse
backgrounds as well as those clients that may have physical disabilities.
3. Staff Composition Chart. Please fill out the following chart.
As of the date this report is submitted, report the number of agency employees.
Indicate whether the employee is salary (W-2) or contract (1099).
THIS INFORMATION RELATES TO
AGENCY WIDE INFORMATION PERSONNEL RESOURCES
TOTAL
W-2
1099
1. Psychiatrist
2. M.D. Non-psychiatrist
3. Psychologist
4. Independently Licensed Clinicians
5. Non-Independently Licensed Clinicians
6. Registered Nurse
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 1-7
DHS Behavioral Health Agency Annual Report – Form 240
Effective July 1, 2017
Page 2 of 4
4. Interagency involvement. Please identify all existing formal or informal contracts the
agency has with other providers or agencies to provide Outpatient Behavioral Health
services. Briefly explain how the agency utilizes and interfaces with other community
resources to provide services for the client.
5. Agency wide quality improvement and outcomes activities. Please include agency
organizational chart and the outcomes of identified quality improvement efforts to improve
client care/outcomes.
As a part of the outcomes activities report include:
a.
Measured outcomes
b.
Sample report
c.
Collection of outcomes, beginning at the initial behavioral health diagnosis service, which would
be completed very close to the client’s intake.
PLEASE SUBMIT THIS FORM AND SUPPORTING DOCUMENTATION TO:
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 Annual Report – Form 240
Effective July 1, 2017
Page 3 of 4
FOR DHS INTERNAL USE ONLY:
1) Cultural/Linguistic Barriers
Yes
No
Status: Complete
2) Staff Composition
Yes
No
Status: Complete
3) Interagency Involvement
Yes
No
Status: Complete
4) Quality Improvement
Yes
No
Status: Complete
5) ACQR MOA PPR
Yes
No
Comments:
DHS Behavioral Health Agency Annual Report – Form 240
Effective July 1, 2017
Page 4 of 4
Page of 4