"Cimor Organization Change Form" - Missouri

Cimor Organization Change Form is a legal document that was released by the Missouri Department of Mental Health - a government authority operating within Missouri.

Form Details:

  • Released on December 6, 2017;
  • The latest edition currently provided by the Missouri Department of Mental Health;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of the form by clicking the link below or browse more documents and templates provided by the Missouri Department of Mental Health.

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Download "Cimor Organization Change Form" - Missouri

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CIMOR Organization Change Form
Instructions
Complete one form for EACH Organization address requiring updates. If an entire site is moving and ALL services will
be offered at the new location, one form will be accepted for the change. This form WILL NOT be accepted to
request certification changes. Those requests must be made directly to the DBH Certification Unit.
Definitions: Organization - Provider or Agency
Primary Address - Physical Location of the Site
Executive Director - Chief Executive Officer, President or SATOP Administrator
Section 1: ALL FIELDS IN THIS SECTION ARE REQUIRED FOR ALL REQUESTS
Reason for Request - Include a detailed description of the changes requested in the
form. Completion of this description does not replace completing the rest of the form.
Effective Date - Date on which the changes will go into effect.
Section 2: Complete ONLY if changes need to be made to the Organization Name or Executive Director
Previous Organization Name - The former name of the organization that is currently showing in CIMOR.
New Organization Name - The organization name as you want it to read in CIMOR.
NOTE: The Parent Organization Name in CIMOR MUST exactly match the name register on the
agency's Federal Tax ID.
Previous Executive Director - The name of the former CEO/President/SATOP Administrator as it currently
appears in CIMOR.
New Executive Director - The name of the new CEO/President/SATOP Administrator as you want it to
appear in CIMOR. Please include the Executive Director's Title.
Section 3: All fields are required when adding new locations or requesting changes to the Physical/Primary Billing
and/or Mailing Address
Administrative Site - Check this box if the site you are requesting changes for is the Administrative location.
Previous Address - Complete this information to identify the location in CIMOR requiring changes.
New Address - Complete this information when a change to the existing address is required or to add new site.
Primary Address - Physical address for the location. This is required on all sites in CIMOR.
Billing Address - Optional address can be added if different from the Physical address.
Mailing Address - Optional address can be added if different from the Physical and/or Billing address.
NOTE - New location must include a Primary Daytime Phone number and the additional 4 digit zip code
extension.
Section 4: Complete the Add/Delete drop down boxes ONLY if changes are required or for a new location
Add - Select 'Add' for new programs and levels that will be offered at the location.
Delete - Select 'Delete' for programs and levels that will be no longer offered at the location.
'Completed By' and 'Regional Representative' Digital Signatures are required for ALL Requests
Completed By - Digital Signature of the person completing the form.
Phone Number - The primary daytime contact number for the person who digitally signed the request.
Regional Representative Digital Signature is required for all requests.
E-mail the completed form with digital signature to the appropriate regional representative:
Eastern Region: Lynne Allar-Meine (Lynne.Allar-Meine@dmh.mo.gov 314-877-0389)
Central Region: Brooke Dawson (Brooke.Dawson@dmh.mo.gov 573-751-2257)
Southeast Region: Scott Giovanetti (Scott.Giovanetti@dmh.mo.gov 314-877-0372)
Western Region: Angie Lewis (Angie.Lewis@dmh.mo.gov 816-482-5779)
For questions about this form, please contact your regional office at the numbers listed above.
CIMOR Organization Change Form
Instructions
Complete one form for EACH Organization address requiring updates. If an entire site is moving and ALL services will
be offered at the new location, one form will be accepted for the change. This form WILL NOT be accepted to
request certification changes. Those requests must be made directly to the DBH Certification Unit.
Definitions: Organization - Provider or Agency
Primary Address - Physical Location of the Site
Executive Director - Chief Executive Officer, President or SATOP Administrator
Section 1: ALL FIELDS IN THIS SECTION ARE REQUIRED FOR ALL REQUESTS
Reason for Request - Include a detailed description of the changes requested in the
form. Completion of this description does not replace completing the rest of the form.
Effective Date - Date on which the changes will go into effect.
Section 2: Complete ONLY if changes need to be made to the Organization Name or Executive Director
Previous Organization Name - The former name of the organization that is currently showing in CIMOR.
New Organization Name - The organization name as you want it to read in CIMOR.
NOTE: The Parent Organization Name in CIMOR MUST exactly match the name register on the
agency's Federal Tax ID.
Previous Executive Director - The name of the former CEO/President/SATOP Administrator as it currently
appears in CIMOR.
New Executive Director - The name of the new CEO/President/SATOP Administrator as you want it to
appear in CIMOR. Please include the Executive Director's Title.
Section 3: All fields are required when adding new locations or requesting changes to the Physical/Primary Billing
and/or Mailing Address
Administrative Site - Check this box if the site you are requesting changes for is the Administrative location.
Previous Address - Complete this information to identify the location in CIMOR requiring changes.
New Address - Complete this information when a change to the existing address is required or to add new site.
Primary Address - Physical address for the location. This is required on all sites in CIMOR.
Billing Address - Optional address can be added if different from the Physical address.
Mailing Address - Optional address can be added if different from the Physical and/or Billing address.
NOTE - New location must include a Primary Daytime Phone number and the additional 4 digit zip code
extension.
Section 4: Complete the Add/Delete drop down boxes ONLY if changes are required or for a new location
Add - Select 'Add' for new programs and levels that will be offered at the location.
Delete - Select 'Delete' for programs and levels that will be no longer offered at the location.
'Completed By' and 'Regional Representative' Digital Signatures are required for ALL Requests
Completed By - Digital Signature of the person completing the form.
Phone Number - The primary daytime contact number for the person who digitally signed the request.
Regional Representative Digital Signature is required for all requests.
E-mail the completed form with digital signature to the appropriate regional representative:
Eastern Region: Lynne Allar-Meine (Lynne.Allar-Meine@dmh.mo.gov 314-877-0389)
Central Region: Brooke Dawson (Brooke.Dawson@dmh.mo.gov 573-751-2257)
Southeast Region: Scott Giovanetti (Scott.Giovanetti@dmh.mo.gov 314-877-0372)
Western Region: Angie Lewis (Angie.Lewis@dmh.mo.gov 816-482-5779)
For questions about this form, please contact your regional office at the numbers listed above.
DEPARTMENT OF MENTAL HEALTH
CIMOR ORGANIZATION CHANGE FORM
SECTION 1: Identification and Reason(s) for Request (REQUIRED FOR ALL REQUESTS)
Organization Name:
Reason for Request:
Effective Date of Changes:
SECTION 2: Organization Name & Executive Director (Complete ONLY if changes are required)
Previous Organization Name:
New Organization Name:
Previous Executive Director:
(Name/Title)
New Executive Director:
(Name/Title)
SECTION 3: Address/Phone/Contact Person (Previous Address is required for all changes)
Administrative Site
Primary Address (Physical Location of Site)
Action
Previous
Street Address
City
State
Zip Code (xxxxx-xxxx)
New
Street Address
City
State
Zip Code (xxxxx-xxxx)
County
Primary Daytime Phone (xxx) xxx-xxxx
Site Fax Number (xxx) xxx-xxxx
Primary Contact Person/Title
Contact Person’s Email Address
Billing Address
Action
Same as Primary
Previous
Street Address
City
State
Zip Code (xxxxx-xxxx)
New
Street Address
City
State
Zip Code (xxxxx-xxxx)
County
Mailing Address
Action
Same as Primary
Previous
Street Address
City
State
Zip Code (xxxxx-xxxx)
New
Street Address
City
State
Zip Code (xxxxx-xxxx)
County
SECTION 4: Select ADD or DELETE on appropriate levels of services. List the affected contract in the box at right.
Compulsive Gambling
Compulsive Gambling
Contract#
CSTAR
Adolescent
Residential
Level 1
Level 2
Level 3
Contract#
General Population
Residential
Level 1
Level 2
Level 3
Contract#
General Population Enhanced
Residential
Level 1
Level 2
Level 3
Contract#
Women & Children
Residential
Level 1
Level 2
Level 3
Contract#
Women & Children Enhanced
Residential
Level 1
Level 2
Level 3
Contract#
Women & Children Alt Care
Residential
Level 1
Level 2
Level 3
Contract#
Detox Program
MMID
Social Setting
Contract#
Contract#
Opioid
General Treatment
Primary Recovery Plus
Detox - SS
Residential
Level 1
Level 2
Level 3
Contract#
ATR Treatment
Contract#
General Treatment
Contract#
Substance Abuse Traffic Offenders Program (SATOP)
Contract#
Offender Management Unit (OMU)
Offender Education Program (OEP)
Adolescent Diversion Education Program (ADEP)
Weekend Intervention Program (WIP)
Clinical Intervention Program (CIP)
Youth Clinical Intervention Program (YCIP)
Serious and Repeat Offender Program/Level IV (SROP)
Required Education Assessment & Community Treatment (REACT)
Support Services
Recovery Support Access
Contract#
Recovery Support
Contract#
Transitional Housing
Contract#
Prevention
Targeted
Contract#
Primary
Contract#
Statewide Resource Center
Contract#
Department of Corrections
Free & Clean Plus
Phase 1
Phase 2
Phase 3
Contract#
Partnership for Community Restoration
Phase 1
Phase 2
Phase 3
Contract#
STL Education
Contract#
Case Management
Contract#
Certified Non-Contracted Services
Detoxification - Medical
Detoxification - Modified Medical
Detoxification - Social Setting
Residential
Opioid
Institutional Corrections
Outpatient – Community-based Primary Treatment
Outpatient – Intensive Outpatient Rehabilitation
Outpatient – Supported Recovery
Completed By:
Contact Email
Primary Daytime Phone (xxxx) xxx-xxxx
Regional Rep:
Regional Representative Comments:
Modified Date: 12/6/2017 (ks)
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