Dbhs Form 1 PDF Details

Database High School, also referred to as Dbhs, is a public high school in San Diego County, California. The school educates students in grades 9-12 and is part of the Sweetwater Union High School District (SUHSD). Database High School offers a variety of academic and extracurricular programs to its students. Some notable programs include the International Baccalaureate (IB) Diploma Programme and the Academy for Business and Technology. In addition to its academic programs, Database High School also boasts a large array of athletic teams that compete at the varsity level. Overall, Database High School is an excellent place for students to receive their education.

QuestionAnswer
Form NameDbhs Form 1
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesDBHS Website DBHS Form 1 rspmi providers arkansas form

Form Preview Example

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: _____________________

 

Telephone: ________________________________

Fax: _____________________

E-mail:

_________________________________________________________________

Website:

_________________________________________________________________

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 (J-CO)

____ 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

________________________________________________________

 

Name of Chief Executive Officer (or equivalent) typed or printed

 

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) 686-9164

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