"Application for Approved Program Status With the Kentucky Department of Corrections for Substance Use Treatment Providers" - Kentucky

"Application for Approved Program Status With the Kentucky Department of Corrections for Substance Use Treatment Providers" - Kentucky Download Pdf
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Application for Approved Program Status With the Kentucky Department of Corrections for Substance Use Treatment Providers is a legal document that was released by the Kentucky Department of Corrections - a government authority operating within Kentucky.

Form Details:

  • Released on June 1, 2020;
  • The latest edition currently provided by the Kentucky Department of Corrections;
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Rev. 6-2020
Application for Approved Program Status with
The Kentucky Department of Corrections for Substance Use
Treatment Providers
TYPE OF APPLICATION
I.
(Check all that apply.)
Initial Approval
Change of Name
Annual Re-Approval
Change of Location
Addition/Change in Service
Change of Ownership
TYPE OF AGENCY
II.
o
Government Agency
o
Private Agency
o
Non-Profit Agency
o
Corporate Agency
TYPE OF SERVICES
III.
(Check all that apply.)
Outpatient Treatment
Intensive Outpatient Treatment
Inpatient Treatment
Partial Hospitalization withdrawal Management Services
Residential Treatment
Residential Transitional Living
Medication Assisted Treatment
Naltrexone
o
Buprenorphine
o
Sublocade
o
Methadone
o
Other _______________________
o
IDENTIFICATION
IV.
AODE License Number:
Name of Facility:
Physical Location of Facility:
(Street)
(City)
(County)
(State)
(Zip Code)
Mailing Address:
(If different from above)
(Street)
(City)
(County)
(State)
(Zip Code)
Telephone Number:
Email Address:
(Primary contact for correspondence)
Site Director/Administrator Name:
Date facility began operating at current address:
/
/
Date facility began operating under current owner:
/
/
pg. 1
Rev. 6-2020
Application for Approved Program Status with
The Kentucky Department of Corrections for Substance Use
Treatment Providers
TYPE OF APPLICATION
I.
(Check all that apply.)
Initial Approval
Change of Name
Annual Re-Approval
Change of Location
Addition/Change in Service
Change of Ownership
TYPE OF AGENCY
II.
o
Government Agency
o
Private Agency
o
Non-Profit Agency
o
Corporate Agency
TYPE OF SERVICES
III.
(Check all that apply.)
Outpatient Treatment
Intensive Outpatient Treatment
Inpatient Treatment
Partial Hospitalization withdrawal Management Services
Residential Treatment
Residential Transitional Living
Medication Assisted Treatment
Naltrexone
o
Buprenorphine
o
Sublocade
o
Methadone
o
Other _______________________
o
IDENTIFICATION
IV.
AODE License Number:
Name of Facility:
Physical Location of Facility:
(Street)
(City)
(County)
(State)
(Zip Code)
Mailing Address:
(If different from above)
(Street)
(City)
(County)
(State)
(Zip Code)
Telephone Number:
Email Address:
(Primary contact for correspondence)
Site Director/Administrator Name:
Date facility began operating at current address:
/
/
Date facility began operating under current owner:
/
/
pg. 1
Rev. 6-2020
V.
OWNERSHIP
(Direct owner)
Name of Owner:
Address of Owner:
(Street)
(City)
(County)
(State)
(Zip Code)
NOTE: Provide the following supporting documentation as an attachment to this
application:
•
The name, mailing address, email address, and phone number of each person or legal entity
having an ownership interest in the facility.
•
If owned by a corporation, the name, mailing address, email address, and phone number of
each officer or director of the corporation.
•
If owned by a partnership, the name, mailing address, email address, and phone number of
each partner.
VI.
ROGRAM EXTENTION SITES
(If more than one extension site, please attach the following
information to the application.)
a.
Number of existing AODE outpatient extension location sites, excluding primary location: __________
b.
Location information: (If more than one outpatient extension location exists, provide the following
information as an attachment to this application.)
Name of Extension Site:
Physical Location:
(Street)
(City)
(County)
(State)
(Zip Code)
Telephone Number:
(Include Area Code)
Director/Administrator:
VII.
EVIDENCE BASED CURRICULUM
(Please include information for each evidence-based curriculum used in the program. Attach additional curriculum
information to this application.)
Name of Curriculum: ____________________________________________________________
Are staff required to receive training or become certified to facilitate?
☐ Yes
☐ No
If yes, how many staff have received the training and/or certified? ____________
VIII.
GROUP DYNAMICS
(Check all that apply)
Groups offered:
☐ AM
☐ Afternoon
☐ Evening
Gender Specific Groups:
☐ Yes
☐ No
IX.
FEE FOR SERVICES
O Client Self Pay: Standard Fee ___________ per group.
O Client Self Pay: Standard Fee ___________ per individual session.
O Client Self Pay: Sliding Scale
pg. 2
Rev. 6-2020
O Private Insurance
O Medicaid
O Other ________________________________
X.
ADDITIONAL DOCUMENTATION CHECKLIST
(To be attached.)
Copy of AODE License
o
(If more than one site, include all documents)
Documentation of all program staff education and verification of any professional license or
o
certification related to counseling.
List of all program staff, including administrative staff not involved in the provision of
o
treatment.
Example of current treatment plan.
o
Section V: Additional Owner/Partner Information
o
(If needed)
Section VI: Program Extension Sites
o
(If needed)
Section VII: Additional Evidence Based Curriculum
o
(If needed)
Other Information About Your Agency or Program
o
X.
SIGNATURE OF AUTHORIZED REPRESENTATIVE
An incomplete application may result in return of the application to the applicant. A completed
application should not be submitted to the Kentucky Department of Corrections at the address listed
at the bottom of the document.
I understand that any change in the information provided within this application affecting the approval status of
this agency or service will be reported to the Department of Corrections, Division of Addiction Services and a new
application will be completed or supplemental information will be provided. I certify that the information given in
completing this application is accurate to the best of my knowledge and recognize that falsification of this
application may result in denial or revocation of licensure.
Signature of Authorized Representative
Title
Date
Submit the completed application and any supportive documentation to:
Kentucky Department of Corrections
Division of Addiction Services
Sarah Johnson, Director
PO Box 2400
Frankfort, KY 40601
SarahG.Johnson@ky.gov
pg. 3
Kentucky Department of Corrections Kentucky Legal Forms United States Legal Forms

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