Comar Application Form – Fill Out and Use This PDF

STATE OF MARYLAND

DHMH

Maryland Department of Health and Mental Hygiene

Office of Health Care Quality

Spring Grove Center ● Bland Bryant Building

55 Wade Avenue ● Catonsville, Maryland 21228-4663

Martin O’Malley, Governor –Anthony G. Brown, Lt. Governor – Joshua M. Sharfstein, M.D., Secretary

APPLICATION PACKET

COMAR 10.47- ALCOHOL AND DRUG ABUSE ADMINISTRATION

Section	Page
Ownership and Emergency Contact Information…………	2
CURRENT Certification Information…………………………….	3
CURRENT Service Level Certification……………………………	4
NEW Level Requests…………………………………………………….	5
Staffing Information…………………………………………………….	6
General Supporting Documentation……………………………	6
Statistics………………………………………………………………………	7

All sections, along with required documentation, are to be completed and returned to the OHCQ - Substance Abuse Unit at the following address:

Office of Health Care Quality

Substance Abuse Certification Unit

Bland Bryant Building – Spring Grove Hospital Center

55 Wade Avenue

Catonsville, MD 21228

Please read and familiarize yourself with COMAR 10.47.Alcohol and Drug Abuse Administration, dated August 2008, prior to completing this application.

Please direct inquiries concerning this application and the application process to the Substance Abuse Certification Unit:

Substance Abuse Unit – (410) 402-8095

Thank you for your attention to these matters.

Toll Free 1-877-4MD-DHMH ● TTY for Disabled – Maryland Relay Service 1-800-735-2258

WEBwww.dhmh.state.md.us

P r o g r a m , O w n e r s h i p a n d E m e r g e n c y C o n t a c t

I n f o r m a t i o n

Ownership Information

Legal Name of Business/Owner:

[ O er is defi ed as a so eo e ho o s is legal possessor of a usi ess; a proprietor. Certifi atio s shall e

issued in the legal name of the business/owner)

Mailing Address of Business/Owner:

City or Town of Business/Owner:					Zip Code
Business/O		er’s We	Site Address:
Busi	ess/O	er’s E ail:
Busi	ess/O	er’s Pho	e Nu	er:
Busi	ess/O	er’s Fa	Nu	er:

Type of Business Organization/Government Agency:

[ Busi ess Orga izatio ” is defined as one of the six forms of business organizations for federal tax purposes.]

Business Organization		Government Agency Type
I.	Sole Proprietorship	VII. Government Agency
II.	**Corporation	a)	City
III.	Partnership	b)	State
IV.	S-Corporation	c)	Federal
V.	Trust
VI. **Non-Profit

**Non-Profit Corporation requires submission of IRS Form 990

	Program Information
Current Program or Trade Name:
[ Trade Na e” is defi ed as The a	e or style u der hi h a o er does usi ess. ]
Program Street Address:
Program Town or City:	Zip Code
Program Web Site:
Program Email:
Program Phone Number:
Program Fax Number:
County of Operation:
National Provider Identification:

(If services are contracted with another State, Federal or Local government department, please attach a copy of the Contract Service Agreement to this application)

Emergency Contact

Must Have Access to Patient Records

Emergency Contact Name:

[ E	erge	y Co ta t is defi ed as: A i di idual ho has a ess to patie t re ords a d a				pro ide patie t o ta t
information at all times. (see COMAR 10.47.01.03D (1)(a)(i).]
Emergency Contact Home Address:
Emergency Contact City or Town:						Zip Code:
E	erge	Co	ta t’s Cell Pho e:
E	erge	Co	ta t’s Offi e Pho		e:
E	erge	Co	ta t’s Ho	e Pho	e:
E	erge	Co	ta t’s E	ail:

2

C U R R E N T C e r t i f i c a t i o n I n f o r m a t i o n

The current certification number is:

[A Curre t Certifi atio Nu er” is defined as the registration or certification number issued to the program after the last survey and formally shown on the progra ’s Ge eral Certifi ate of Appro al issued ADAA.]

The current certification for this Program expires on:

[ Certifi atio E piratio ” is defi ed as the e piratio date fou d o the progra ’s Ge eral Certifi ate of Appro al issued by ADAA.]

Not Applicable (please check)

[ Not Appli a le” would apply on applications for initial program applications, i.e., those programs that have not previously been issued a program certification number by ADAA.]

Type of Certification Requested on this Application

Please Note: This application may be used for combinations of certification requests, e.g. a renewal application may also include a change in program location or an addition or deletion of service level. Please check all that apply. However, a

separate application packet must be completed for each physical site.

Initial Certification Request (SEE COMAR 10.47.04.04A)

[A I itial Certifi atio ” is defined as an application submitted by an owner for the first certification of a program that has never previously been certified by the ADAA. This certification is valid for a period not to exceed six months.]

Renewal of General Certification Request (SEE COMAR 10.47.04.04C)

[A Re e al of General Certification” is defined as a certification which is provided to a currently certified program whose certification period is about to expire or has expired and the program is not requesting a change in program service level.]

Change of Program Location Certification Request (SEE COMAR 10.47.04.03G & 10.47.04.04D (6)

[A Cha ge of Progra Lo atio Certifi atio ” is defined as a request for certification of a program that has changed the physical location of its place of business, i.e. the site where the program provides its services to patients or a change in location of its administrative offices.]

Change in Service Levels Request (SEE COMAR 10.47.04.03D)

[A	Cha	ge i	“er i e Le els	is defined as the addition or deletion of a program service level. (see COMAR
10.47.02.03 thru 10.47.02.11)]
Change in Program Ownership (SEE COMAR 10.47.04.03G)
[A	Cha	ge i	Progra O	ership is defi ed a	ir u sta es i hi h the o ership of the pre iously

certified program is sold, transferred or reassigned.]

Initial or Renewal Certification of Opioid Maintenance Therapy Program(s) (SEE COMAR 10.47.02.11)

An application fee of $700 is required with the initial application and at recertification, if the program provides opioid maintenance therapy (Opioid Maintenance Therapy Programs). Checks shall be payable to DHMH/OHCQ.

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C U R R E N T S e r v i c e L e v e l C e r t i f i c a t i o n

(See COMAR 10.47.02.03 thru 10.47.02.11 & 10.47.03.03 thru 10.47.03.07). Please check all that apply and write

under each category the # of adults, adolescents and/or children you serve.

Outpatient Services

Adults

Adolescents

Children

Level 0.5 Early Intervention

Level 0.5 Early Intervention: DWI Ed

Level I – Outpatient

Level II.1 Intensive Outpatient

Level II.5 Partial Hospitalization

Residential Services

Adults

Adolescents

Children

Level III.1 Clinically Managed Low Intensity Residential

Level III.3 Clinically Managed Medium Intensity

Level III.5 Clinically Managed High Intensity Residential

Level III.7 Medically Monitored Intensive Inpatient Treatment

Detoxification Services

Adults	Adolescents	Children

Level I.D Ambulatory Detoxification w/o Extended On-site Monitoring

Level II.D Ambulatory Detoxification with Extended On-site Monitoring

Level III.2-D Clinically Managed Residential Detoxification

Level III.7-D Medically Monitored Inpatient Detoxification

Opioid Maintenance Therapy

Adults

Adolescents

OMT - Opioid Maintenance Therapy

**OMT.D – Only Opioid Maintenance Therapy Detoxification

**(Check only if a State & Federally Approved Opioid Treatment Program)

Correctional Service Levels

Select if a Specific Program Requirement

Correctional Level I

Correctional Level II.1

Correctional Level II.5

Correctional Level III.1

Correctional Level III.5

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S t a f f i n g I n f o r m a t i o n

Please Provide The Listed Information (As Required By COMAR 10.47.01.06) For These Required Staff Positions.

Sponsor

Information required for Opioid Maintenance Therapy Programs only - 42 CFR Part 8.2

Name of Sponsor:

Mailing Address of Sponsor:

City or Town of Sponsor:

Spo	sor’s E-mail Address:
Spo	sor’s Pho e Nu er:

Program

Progra Ad	i istrator’s Name:
Medi al Dire tor’s Name:
Cli i al Super	isor’s Na e:

G e n e r a l S u p p o r t i n g D o c u m e n t a t i o n

Please Provide With This Application The Following Supporting Documentation

Governing Body

A roster of the e er or e ers of the progra ’s governing body as required by COMAR 10.47.01.03. The roster

shall have the name and mailing address of all members.

(A Go er i g Bod ” means the organizational structure that is responsible for establishing policy, maintaining quality care, and

providing management and planning for the program.

Organizational Chart

The chart shall show schematically the staff positions maintained by the program, detailing lines of authority and

responsibility, and the individual names of staff members currently employed in those positions including all clinical staff

employees.

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R e q u i r e d S t a t i s t i c s

The number of patients receiving services at the time of the application:

(The u er of patie ts re ei i g ser i es is defi ed as the TOTAL u er of patients receiving program services on the day the application is submitted to OHCQ irrespective of the type of services those patients are receiving. An application, for example, requesting an Initial Certification would have a patient census of zero at the time of the application submittal.)

This Program Will Provide The Following Language/Communication Services

	Please Check all that Apply
Spanish			Services for the Hearing Impaired
American Sign Language			Other Language service(s):

	This Program Will Serve
Adolescents (12-17 years of age)	Adult Females
Adult Males	Pregnant Women
	Women with Children
This program will receive public funds from the following sources
	Please Check all that Apply
Medicaid	Start Up Funds
Medicare	Federal Funds
Medical Assistance	Local Government Funds

(Please note: If any of the above funding sources are checked please contact ADAA to determine reporting

requirements!)

Mental Health

Check Only One

Co-Occurring Enhanced (refer to the American Society of Addiction Medicine-Patient Placement Criteria)

Co-Occurring Capable (Refer to ASAM-PC)

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