Form MH-4385 "Initial Application for License to Operate a Facility and/or Service Providing Mental Health, Substance Abuse, or Personal Support Services" - Tennessee

What Is Form MH-4385?

This is a legal form that was released by the Tennessee Department of Mental Health & Substance Abuse Services - a government authority operating within Tennessee. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on May 15, 2020;
  • The latest edition provided by the Tennessee Department of Mental Health & Substance Abuse 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 fillable version of Form MH-4385 by clicking the link below or browse more documents and templates provided by the Tennessee Department of Mental Health & Substance Abuse Services.

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Download Form MH-4385 "Initial Application for License to Operate a Facility and/or Service Providing Mental Health, Substance Abuse, or Personal Support Services" - Tennessee

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INITIAL APPLICATION FOR LICENSE
TO OPERATE A FACILITY AND/OR SERVICE PROVIDING MENTAL HEALTH, SUBSTANCE ABUSE, OR PERSONAL SUPPORT SERVICES
INSTRUCTIONS: This application may be made by the individual owner, chief executive officer, executive director, or other member of the governing body on whom
rests the authority and responsibility for maintaining standards, policies, and procedures for the facility/service to be operated. (Please type or print legibly.) This
application and accompanying documents are to be submitted to the Office of Licensure in the region where license is to be issued.
1.
DATE OF APPLICATION:
Month: ___________________________ Day: _________________________ Year: _____________________
2.
APPLICANT NAME(S) if applying as individual/joint proprietor(s)
OR
CORPORATE NAME if registered with TN Secretary of State:
_______________________________________________________________________________________________________________________________
3.
IDENTIFICATION OF PERSON WHO HAS OVERALL RESPONSIBILITY FOR THE AGENCY/COMPANY: For individual proprietors or partnerships, name
one of the individuals listed in #2. For corporations, associations, or other organizations, this may be the chief executive officer, executive director, etc.
NAME: ________________________________________________________ TITLE: __________________________________________________________
PHONE NUMBER: _________________________ FAX NUMBER: ________________ EMAIL ADDRESS: ________________________________________
Check here if a management firm has been contracted to oversee the management of the facility and/or service.
Name of Management Firm and Account Manager: _________________________________________________________________________________
NOTE: A copy of the contract between the corporation and the management firm listed above must be submitted with this application.
4.
CONTACT INFORMATION OF INDIVIDUAL RESPONSIBLE FOR INVOICES AND COMPLIANCE DOCUMENTS:
NAME: ____________________________________________________________ TITLE: ______________________________________________________
PHONE NUMBER: _________________________ FAX NUMBER: _______________ EMAIL ADDRESS: _________________________________________
BILLING ADDRESS: ______________________________________________________________________________________________________________
CITY: _________________________________________________ STATE: ___________________________ ZIP CODE: ___________________________
5.
ORGANIZATIONAL STRUCTURE: (check one of the following)
Individual/Joint Proprietorship
Partnership
Association
 
Limited Liability Corporation
Church
Government Agency or State University
 
Non-Profit Corporation
For Profit Corporation
Other
__________________________________
 
6.
CORPORATION/ASSOCIATION INFORMATION. Note: This item must be answered only by those applicants having a corporation, association, or
other collective type of organizational structure. A corporation must submit a copy of its corporate charter as certified by the Tennessee Secretary of State.
(Sole proprietors, partnerships, government agencies, and state universities do not complete this item.)
List below the names, titles or positions, and city/state of residence of each person having membership in the governing body of the corporation, association,
church, or other organization. (For example, Owner/Co-Owner, President, Vice-President, Board of Director members, elders, etc.)
Name
Title/Position
City/State of Residence
__________________________________
________________________________
____________________________
__________________________________
________________________________
____________________________
__________________________________
________________________________
____________________________
__________________________________
________________________________
____________________________
(If necessary, continue listing on separate sheet and check here .)
MH-4385 (rev. 05/15/2020)
Page 1 of 3
INITIAL APPLICATION FOR LICENSE
TO OPERATE A FACILITY AND/OR SERVICE PROVIDING MENTAL HEALTH, SUBSTANCE ABUSE, OR PERSONAL SUPPORT SERVICES
INSTRUCTIONS: This application may be made by the individual owner, chief executive officer, executive director, or other member of the governing body on whom
rests the authority and responsibility for maintaining standards, policies, and procedures for the facility/service to be operated. (Please type or print legibly.) This
application and accompanying documents are to be submitted to the Office of Licensure in the region where license is to be issued.
1.
DATE OF APPLICATION:
Month: ___________________________ Day: _________________________ Year: _____________________
2.
APPLICANT NAME(S) if applying as individual/joint proprietor(s)
OR
CORPORATE NAME if registered with TN Secretary of State:
_______________________________________________________________________________________________________________________________
3.
IDENTIFICATION OF PERSON WHO HAS OVERALL RESPONSIBILITY FOR THE AGENCY/COMPANY: For individual proprietors or partnerships, name
one of the individuals listed in #2. For corporations, associations, or other organizations, this may be the chief executive officer, executive director, etc.
NAME: ________________________________________________________ TITLE: __________________________________________________________
PHONE NUMBER: _________________________ FAX NUMBER: ________________ EMAIL ADDRESS: ________________________________________
Check here if a management firm has been contracted to oversee the management of the facility and/or service.
Name of Management Firm and Account Manager: _________________________________________________________________________________
NOTE: A copy of the contract between the corporation and the management firm listed above must be submitted with this application.
4.
CONTACT INFORMATION OF INDIVIDUAL RESPONSIBLE FOR INVOICES AND COMPLIANCE DOCUMENTS:
NAME: ____________________________________________________________ TITLE: ______________________________________________________
PHONE NUMBER: _________________________ FAX NUMBER: _______________ EMAIL ADDRESS: _________________________________________
BILLING ADDRESS: ______________________________________________________________________________________________________________
CITY: _________________________________________________ STATE: ___________________________ ZIP CODE: ___________________________
5.
ORGANIZATIONAL STRUCTURE: (check one of the following)
Individual/Joint Proprietorship
Partnership
Association
 
Limited Liability Corporation
Church
Government Agency or State University
 
Non-Profit Corporation
For Profit Corporation
Other
__________________________________
 
6.
CORPORATION/ASSOCIATION INFORMATION. Note: This item must be answered only by those applicants having a corporation, association, or
other collective type of organizational structure. A corporation must submit a copy of its corporate charter as certified by the Tennessee Secretary of State.
(Sole proprietors, partnerships, government agencies, and state universities do not complete this item.)
List below the names, titles or positions, and city/state of residence of each person having membership in the governing body of the corporation, association,
church, or other organization. (For example, Owner/Co-Owner, President, Vice-President, Board of Director members, elders, etc.)
Name
Title/Position
City/State of Residence
__________________________________
________________________________
____________________________
__________________________________
________________________________
____________________________
__________________________________
________________________________
____________________________
__________________________________
________________________________
____________________________
(If necessary, continue listing on separate sheet and check here .)
MH-4385 (rev. 05/15/2020)
Page 1 of 3
7.
BACKGROUND AND HISTORY: Proof of citizenship or evidence of legal immigration, a Background Information Check form, and a Non-Criminal Justice
Privacy Rights Statement must be submitted on the individual listed in item #3 and any additional individuals listed in #2. Additionally, a fingerprint background
check through the Tennessee Bureau of Investigation is required for this individual. (A fingerprint background through the FBI or a background check
conducted by a state-licensed private investigator is acceptable but must include a check of current and previous states of residence, if any.) If the individual
chooses to be fingerprinted by the TBI, an appointment will be scheduled by the Office of Licensure.
(Cost of background check is the responsibility of the individual.)
The following questions are to be answered about the individual listed in item #3 and any additional applicants listed in #2.
a.
Has the applicant or any responsible person referenced above ever been convicted, or currently under any charges, for offense against the law? (Note:
You may exclude traffic violations for which a fine of less than $100 was paid, and any offense that was committed before a person’s eighteenth birthday
and finally adjudicated in a juvenile court or under youth offender law.
 YES
 NO
If YES, provide person’s name, date and place of offense, type of charge, and action taken:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
b.
Has the applicant or any person responsible for the corporation ever held a license or certificate from this state, or any other state, to operate a
facility/service for providing mental health, substance abuse, or personal support services, or services to persons in need of other protective or supportive
services, such as a nursing home, residential home for the aged, child or adult day care, foster homes, etc.?
 YES
 NO If YES, provide person’s name, dates of operation, facility/service name and location, and licensing agency/state dept:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
c.
Has the applicant or any person responsible for the corporation ever held a license or certificate in this state, or any other state, to practice a regulated
profession (such as physician, nurse, facility administrator, social worker, attorney, psychologist, etc.), and had such license revoked, denied, or
suspended?
 YES
 NO If YES, provide person’s name, profession, date, state, and action taken against such license or certificate:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
8.
PERSONAL INFORMATION: The following questions are to be answered about the individual listed in item #3 and any additional applicants listed in #2.
a.
Full Name: _________________________________________________________
Social Security Number: _______________________________
Place of Birth: _______________________________________________________
Date of Birth: ________________________________________
b.
Year and degree or grade of highest level of education achieved: Year: _________ Degree: ______________________________________________
Name of school/college/university ______________________________________________________________________________________________
c.
Current home address: Street Address: _________________________________________________________________________________________
City/State/Zip: __________________________________________________________________________________________
d.
If residing at current address less than five years, give previous address:
Street Address: ________________________________________________________________________________________
City/State/Zip: __________________________________________________________________________________________
e.
List previous employment or business occupation for the past five years:
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
________________________________________________________________________________________________________________
(If more than one individual and/or if additional space is needed to answer any of the above, attach separate sheet and check here .)
MH-4385 (rev. 05/15/2020)
Page 2 of 3
9.
REFERENCES: List below the name and address or email address of three individuals who can attest that the individual listed in item #3 and any additional
applicants listed in #2 is of reputable character or reputation, and has the ability to operate a facility/service providing services to persons who are vulnerable to
neglect, abuse, and exploitation. Individuals providing a reference may not be related to the applicant by marriage, blood, or in a vested business venture.
1.
Name: ___________________________________________________________________________________________________________________
Mailing address or email address: ______________________________________________________________________________________________
2.
Name: ___________________________________________________________________________________________________________________
Mailing address or email address: ______________________________________________________________________________________________
3.
Name: ___________________________________________________________________________________________________________________
Mailing address or email address: ______________________________________________________________________________________________
(If more than one individual, attach separate sheet and check here .)
10. ACCREDITATION/CERTIFICATION STATUS:
(OPTIONAL: Accreditation or certification of an applicant’s facility/service is not required in order to be
approved for license.)
Participation in any of the following accreditation or certification programs may qualify a facility/service to be deemed into compliance
with certain programmatic rules of licensure. To be considered for a possible deemed status determination, the applicant must submit documentation showing
current accreditation or certification status for the facility/services/programs covered by such status, the effective dates of the status, and the findings of the
accrediting or certifying body, including any deficiencies with plans of correction. The following accreditation and certification programs are recognized by the
Department of Mental Health and Substance Abuse Services; check any applicable participation:
 
Accreditation of Health Care Organizations
Council on Accreditation
Division of Intellectual Disabilities Services (DIDS)
Council on the Accreditation of Rehabilitation Facilities (CARF)
 
 
The Joint Commission
Council on Quality and Leadership (CQL)
 
Other: _____________________________________________
11. FINANCIAL RESOURCES:
(NOTE: This item only applies to applicants/corporations applying for an A&D Non-Residential Office-Based Opiate
Treatment license.)
The applicant must show financial solvency and responsibility to operate a facility/service. The applicant must provide a proposed budget
for the facility's operation, or the most recent fiscal report or financial statement or other information which is complete and sufficient in showing the total assets,
liabilities and income of the applicant. The Licensure Application Addendum: Financial Statement Form available on the Office of Licensure website may be
used in lieu of the fiscal report or financial statement.
12. DESCRIPTION OF FACILITY/SERVICES: The licensure rules identify and describe distinct categories of facilities/services which meet differing rules based on
the type of service provided and the needs of the persons served.
A Licensure Addendum: Fact Sheet Form identifying the services to be provided must
be submitted for each location to be operated by the applicant.
13. APPLICATION/LICENSE FEE: The fee amount is based on the number of distinct, non-residential categories to be operated at each non-residential site
and/or the number of service recipient beds for each distinct residential facility site. Fee schedule is listed in the Licensure Administrative Rules Chapter 0940-
05-02.05. Upon receipt of Initial Application and Licensure Application Addendum: Fact Sheet Form, the Office of Licensure will send an invoice with the
appropriate fee amount and mailing instructions.
FEES ARE NON-REFUNDABLE.
CERTIFICATION OF APPLICATION. Certification of Application is to be signed by the individual applicant, in the case of a proprietorship or partners; or the CEO,
President, Chairperson, or equivalent officer in the case of a corporation or other association; or the person charged with the oversight of the facility/service by the
appointing authority in the case of a governmental agency or state university.
I hereby declare that this application and its accompanying attachments have been carefully read and completed, and to the best of my knowledge, they are true,
correct and complete. I further declare my authority and responsibility to make this application and agree to comply with the rules promulgated under Tennessee
Code Annotated, Title 33, Chapter 2, Part 4, for the conduct of a facility/service providing mental health, substance abuse, or personal support services.
_________________________________________________________________________
_____________________________________________________
SIGNATURE OF APPLICANT OR AUTHORIZED AGENT
TITLE
_________________________________________________________________________
_____________________________________________________
TYPE OR PRINT NAME
DATE
Send completed forms and accompanying documentation to appropriate regional office.
East Tennessee Regional Office
Middle Tennessee Regional Office
West Tennessee Regional Office
520 West Summit Hill Drive
500 Deaderick Street
951 Court Avenue
Suite 502
5
Floor, Andrew Jackson Bldg.
Memphis, TN 38103
th
Knoxville, TN 37902
Nashville, TN 37243
Telephone #: 901-543-7442
Telephone #: 865-594-6551
Telephone #: 615-532-6590
Fax #: 844-844-5538
Fax #: 844-340-4482
Fax #: 615-532-7856
Email:
LicensureWest.fax@tn.gov
Email:
LicensureEast.fax@tn.gov
Email:
LicensureMiddle.fax@tn.gov
MH-4385 (rev. 05/15/2020)
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