Form 250 "Behavioral Health Agency New Site Application" - Arkansas

What Is Form 250?

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 250 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 250 "Behavioral Health Agency New Site Application" - Arkansas

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Arkansas Department of Human Services
Behavioral Health Agency New Site Application
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:
Email: ___________________________
Date New Site Opened:
Chief Executive Officer (or equivalent) Certification: By my signature, I certify that I have reviewed
this application 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 New Site Certification – Form 250
Effective July 1, 2017
Page 1 of 4
Arkansas Department of Human Services
Behavioral Health Agency New Site Application
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:
Email: ___________________________
Date New Site Opened:
Chief Executive Officer (or equivalent) Certification: By my signature, I certify that I have reviewed
this application 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 New Site Certification – Form 250
Effective July 1, 2017
Page 1 of 4
PERSONNEL RESOURCES FOR NEW SITE ONLY
SFY
(As of the date this report is submitted)
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
PROGRAM RESOURCES FOR NEW SITE ONLY
(Round to nearest whole number)
10. Number of counties in service area
11. Number of counties in service area in which agency operates a service site
12. Total number of service sites operated by Agency
13. Average daily clients served by Agency
14. Number of School Based Behavioral Health Programs run by agency
15. Total projected daily average of clients in all school based sites combined
16. Total projected number of clients served in the outpatient clinic
17. Please list other mental health services provided by the organization and
provide capacity information, as appropriate (i.e. residential beds, crisis
beds, inpatient beds, housing, therapeutic foster care, partial hospitalization,
therapeutic communities, etc.)
17.A.
17.B.
17.C
17.D
If more room is needed, please list on a separate page and attach to this report.
CONTACT INFORMATION
18. Contact person regarding this report
19. Telephone number of contact person for this report
20. E-mail address of contact person for this report
DHS Behavioral Health Agency New Site Certification – Form 250
Effective July 1, 2017
Page 2 of 4
PERSONNEL QUALIFICATIONS & RESOURCES
1. Attach administrative structure for the new site(s) for which extension of certification is
being requested.
2. Attach licenses or certifications and resumes of all administrators of the new site. Include the
medical director or consulting psychiatrist information if different from the main office site.
3. Attach any contracts with consulting professionals specific to the new site only if additional
to the original certification.
PHSYICAL PLANT
1. Attach a list of all new service delivery sites including each site’s address (street, city &
county), telephone number, fax number, the name of the designated contact person, for each
site and that person’s email address, the geographic area served by each site and the
Outpatient Behavioral Health services available at each site.
2. Attach a photograph of each service delivery site for which you are requesting a certification
extension. Include outside entrance to building, staff offices, and waiting area.
SERVICE DELIVERY PLAN CURRENTLY IN PLACE
FOR EACH NEW SITE
In a narrative report, describe the agency’s plan for the provision of services including all
requested information in compliance with the current Behavioral Health Agency Certification
Policy and Outpatient Behavioral Health Services Medicaid Manual. Please utilize the following
format:
1. Type of services available at additional site/s, hours of operation and type of clients served (i.e.
children, adults, Seriously Mentally Ill, Seriously Emotionally Disturbed, Juvenile Justice
Population, etc.)
2. 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 DBHS.
3. Description of agency’s crisis services plan that is available at the new site including the
policy and procedures for provision of crisis services 24 hours a day 7 days a week.
4. Briefly explain how the new site will utilize and interface with other community resources to
provide services for the client.
5. Describe how the new site will be integrated into the Quality Improvement Program of the
agency.
DHS Behavioral Health Agency New Site Certification – Form 250
Effective July 1, 2017
Page 3 of 4
ACCREDITATION INFORMATION
I. Attach documentation notifying your accrediting organization of the site(s) additions and the
accrediting organization’s acknowledgement of the accreditation extension. Certification extension
WILL NOT BE GRANTED until you have the accrediting organization’s documentation.
II. Include dates of current accreditation cycle.
Reimbursement by Arkansas Medicaid services shall not occur until the site is certified by
the Department of Human Services.
Please send this form along with your application 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 New Site Certification – Form 250
Effective July 1, 2017
Page 4 of 4
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