In the realm of behavioral health services, maintaining proper communication and adherence to protocols during significant transitions is paramount. The Arkansas Department of Human Services Division of Behavioral Health Services (DBHS) has instituted a specific procedure for handling the closing or relocation of a Rehabilitation Services Program for Mental Illness (RSPMI) provider site, encapsulated within the DBHS 4 form. This form plays a crucial role in ensuring that the transition does not disrupt the continuity of care for clients. It mandates that providers moving a site—which is considered both a closure of the original site and the opening of a new one within a fifty-mile radius—must notify the accrediting agency, DBHS, and Medicaid at least thirty days before the move. Notably, this change does not require an on-site survey nor a new Medicaid number for the new location to extend its certification. The form seeks comprehensive information, such as details of the agency, the chief executive and compliance officers, and both the old and new addresses, ensuring a seamless transition. It emphasizes the critical importance of maintaining certification and accreditation through the transition, illustrating a high standard of care and compliance in the behavioral health sector.
| Question | Answer |
|---|---|
| Form Name | Dbhs Form 4 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | DBHS Website DBHS Form 4 arkansas dbhs form 4 |
ARKANSAS DEPARTMENT OF HUMAN SERVICES
DIVISION OF BEHAVIORAL HEALTH SERVICES
NOTIFICATION FORM FOR CLOSING OR MOVING OF
AN RSPMI PROVIDER SITE
Moving a site constitutes a closing of one site and a move of the program(s), move of existing staff and move of existing client base to another location. If a provider relocates a currently certified site within a fifty (50) mile radius the accrediting agency, DBHS and Medicaid must be notified thirty (30) days prior to that relocation. Neither an
Name of Agency:_______________________________________________________
Chief Executive Officer (or equivalent): _____________________________
Corporate Compliance Officer (or equivalent): ___________________________
Administrative Address: ____________________________________________
_______________________________________________________________
Telephone: ______________________ Fax: _______________________
This is notification that the following site(s) have: ________ moved ______closed
CLOSING Date of Closing: ______________________
ADDRESS:
_____________________________________________
_____________________________________________
_____________________________________________
MOVING Date of Move: ________________________
PREVIOUS ADDRESS (Include: street, city, county, telephone & fax) NEW ADDRESS
___________________________________________________
___________________________________________________
___________________________________________________
Please attach all documentation to and from your accrediting organization regarding the above information. Certification will not be granted to the new site address until all information from the accrediting organization indicates that the new site address is accredited.
Chief Executive Officer (or equivalent) Certification: By my signature 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 4
Page Two
Notification Form for Closing/Moving
1.In addition to this form, please provide any information that is specific to the site/s for which certification is being requested that is different from those agency sites already certified by DBHS.
2.Include a photograph of outside entrance to building, staff offices, and waiting area for all new site locations.
If you have any questions, please contact the Division of Behavioral Health Services at (501)
Please send this form with required documentation to the following address:
Division of Behavioral Health Services
Policy & Certification Office
305 South Palm Street
Little Rock, AR 72205
DBHS Form 4