In the intricate landscape of healthcare services, the process of certification stands as a crucial step for agencies aiming to offer Rehabilitation Services Program for the Mentally Ill (RSPMI) under the aegis of the Arkansas Department of Human Services' Division of Behavioral Health Services (DBHS). The DBHS 1 form, a key document in this process, serves as a beacon for agencies navigating the rigorous path towards becoming a qualified RSPMI provider. This form, required to be completed upon the initial application for DBHS RSPMI Certification, encapsulates essential information including the agency's name, key personnel such as the Chief Executive Officer and Corporate Compliance Officer, and contact details. Furthermore, it probes into the agency's accreditation status with reputable organizations like the Joint Commission on Accreditation of Healthcare Organizations, Commission on Accreditation for Rehabilitation Facilities, or the Council on Accreditation. Its significance is underscored by the necessity for meticulous documentation, including the latest accreditation survey results, correspondence with accrediting organizations, and a comprehensive agreement that allows DBHS access to relevant information directly from these entities. Moreover, the form mandates the submission of evidence pertaining to compliance, achievements, and improvement plans related to outpatient mental health services, alongside the annual RSPMI Services and Resource Summary Report, thus ensuring a thorough vetting process that upholds the highest standards of care and compliance.
| Question | Answer |
|---|---|
| Form Name | Dbhs Form 1 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | DBHS Website DBHS Form 1 rspmi providers arkansas form |
ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIVISION OF BEHAVIORAL HEALTH SERVICES
QUALIFICATION FORM FOR RSPMI PROVIDER CERTIFICATION
BY THE DIVISION OF BEHAVIORAL HEALTH SERVICES
To be completed upon initial application for DBHS RSPMI Certification.
Name of Agency: _______________________________________________________________
Chief Executive Officer (or equivalent): ______________________________________________
Corporate Compliance Officer (or equivalent):__________________________________________
Administrative Address: __________________________________________________________________
County: _____________________ |
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Telephone: ________________________________ |
Fax: _____________________ |
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_________________________________________________________________ |
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Website: |
_________________________________________________________________ |
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The provider named above is fully accredited and in good standing with one of the following accreditation organizations. (Please check your accreditation organization)
____ Joint Commission on Accreditation of Healthcare Organizations
____ Commission on Accreditation for Rehabilitation Facilities (CARF)
____ Council on Accreditation (COA)
Date(s) of most recent survey: ___________________________
Accreditation Period: ____________________ through ____________________
The accredited provider is located within the State of Arkansas.
______ Yes |
______ No |
As the Chief Executive Officer (or equivalent) of the agency named above, I verify that all information contained in this form and in all attachments is correct and complete.
________________________________________________________ |
__________________ |
Signature of Chief Executive Officer (or equivalent) |
Date |
________________________________________________________ |
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Name of Chief Executive Officer (or equivalent) typed or printed |
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DBHS FORM 1
Qualification Form for RSPMI Provider Certification
All of the following information must be attached to the Qualification Form for RSPMI Certification (DBHS Form 1). Applications must be submitted in full.
1.Latest accreditation survey results. (The entire survey report covering outpatient mental health services must be included.)
2.Copies of all correspondence and e mails (e mails may be copied to the DBHS office) between the agency and the accrediting organization that pertains to the accreditation of the provider’s outpatient mental health services.
3.A signed agreement that DBHS may receive information directly from the accrediting organization regarding the agency’s accreditation and any information pertaining to service delivery. (See DBHS Form 1 Attachment #1)
4.All Evidence of Compliance, Measures of Success, Performance Improvement Plans, and any Corrective Action Plans submitted to the accreditation organization pertaining to outpatient mental health services.
5.Annual RSPMI Services and Resource Summary Report with all attachments as designated in the RSPMI Services and Resource Summary Form (DBHS Form 2).
DBHS WILL SCHEDULE AN ONSITE SURVEY WITHIN TWENTY (20) CALENDAR DAYS OF APPROVING ALL REQUIRED CERTIFICATION DOCUMENTATION.
If you have any questions, please contact the Division of Behavioral Health Services at (501)
Please send a cover letter and all application materials to be certified by DBHS as an RSPMI Provider to the following address:
Division of Behavioral Health Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
DBHS FORM 1
ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIVISION OF BEHAVIORAL HEALTH SERVICES
OFFICE OF POLICY AND CERTIFICATION
Accreditation Organization Release of Information Consent
I, __________________________, hereby consent to the exchange of information between
CEO (or equivalent)
___________________________________________________________________________ and
Accrediting Agency
The Division of Behavioral Health Services, Policy and Certification Office, for the specific purpose of obtaining or sharing information relevant to RSPMI Provider Certification.
I consent to information regarding my agency’s national accreditation or state certifications being released by facsimile (FAX) __________ Yes ___________ No.
I understand that the information I authorize for release may include sensitive information. I understand that a facsimile of this consent is considered as valid as if it were the original.
__________________________________________________ |
___________________ |
Signature of CEO (or equivalent) |
Date |
__________________________________________________ |
___________________ |
Signature of Witness |
Date |
DBHS FORM 1