DHCS 6002 Form – Fill Out and Use This PDF

The attached application is to be used by current and prospective providers that wish to apply for Substance Use Disorder (SUD) treatment program initial residential licensure, initialcertification, merger with another legal entity or change of ownership of an existing facility. Current providers wishing to relocate, add or delete treatment services, increase/decrease treatment beds or change target population must complete the Supplemental Application DHCS 5255 ­ (Rev. 6/16). All items in blue underline throughout the applicationsignifies a link to the specified website.

It is vital that you carefully read each component (including the regulations and/or standards) before beginning to fill out the application. Answer each question in the application, and submit only the documentation requested and required. An incomplete application results in a delay of the application process.

If, after you have read the entire application packet, you determine that you would like technical assistance or training addressing certain elements of the application process, you mayrequest assistance, free of charge, from the Department of Health Care Services (DHCS)consulting agency. Please check the Department's website for the current technical assistance provider.

If you have any questions regarding the licensing or certification of SUD recoveryor treatment facilities, please contact DHCS’s SUD Compliance Division at (916)322­2911.

Public Information

Information provided by the applicant can be made available for public review, unless otherwise exempted by law (Inspection of Public Records, Chapter 3.5, Division 7, GovernmentCode).

Requirements for License

The California Code of Regulations (CCR), Title 9, Division 4, Chapter 5, §10505, states, inpart, that no person, firm, partnership, association, corporation, or local government entity shalloperate, establish, manage, conduct, or maintain an alcoholism or drug abuse recovery or treatmentfacility without obtaining a current, valid license pursuant to thischapter.

An alcoholism or drug abuse recovery, treatment, or detoxification facility is defined as any facility, place or building which provides 24­hour, residential, non­medical services in a group settingto adults. For the purpose of further defining whether licensure is required, alcoholism or drugabuse recovery or treatment services mean services which are designed to promote treatment and maintain recovery from substance use disorder problems which include one or more of the following: detoxification, group sessions, individual sessions, educational sessions, and recovery ortreatment planning.

Regulations

The regulations that govern the licensing of non­medical residential facilities covered by these application instructions are under CCR, Title 9, Division 4, Chapter 5. In order to assist applicants in supplying the detailed information needed in the licensing process, a copy of the regulations maybe downloaded from the California Office of Administrative Law website. The pertinent regulations are listed under the Department and Alcohol and DrugPrograms.

For information on purchasing the regulations, including the receipt of updates, please contact Barclays West Group online or by phone at 1­800­888­3600.

Requirements forCertification

The Health and Safety Code, §11830, offers certification of residential and outpatientprograms on a voluntary basis. Although certification is voluntary, programs wanting to ensure quality assurance, while expanding the availability of funding resources, will requestcertification.

Many programs consider certification advantageous in gaining the confidence of potentialclients, insurance companies, and other third­party payers, as it signifies that a program meets minimal levels of service quality. In addition, many counties require that programs under contract be SUD certified as a condition of receivingfunds.

CertificationStandards

The standards that govern certified programs covered by these instructions are within the Alcohol and Other Drug Certification Standards, and may be downloaded from the DHCS website.

Requirements for Drug Medi­Cal Certification(DMC)

CCR Title 22, offers DMC certification to programs that provide substance abuse servicesto Medi­Cal beneficiaries that are covered by the Medi­Cal program, when it is determined, by a physician, that alcohol and drug treatment is medicallynecessary.

If you intend to provide residential DMC services, you must first complete this application and be issued a residential license prior to submitting an application for DMC residentialservices.

The DMC certification requirements for substance abuse clinics are contained in the DrugMedi­Cal Certification Standards for Substance Abuse Clinics; the Alcohol and/or Other Program Certification Standards; and CCR Title 22, Sections § 51341.1, § 51490.1, and §51516.1.

To assist applicants in supplying the detailed information needed in the DMC certificationprocess, a copy of the regulations and standards can be downloaded from the Drug Medi­Cal Certification page. DMC applications must be submitted separately to:

PROVIDER ENROLLMENT DIVISION

MS 4704 PO Box 997412

Sacramento, CA 95899­7412

(800) 541­5555 or (916) 323­1945

Treatment Provider Application Fees

DHCS assesses fees to all licensed and/or certified residential and certified outpatientSUD recovery and treatment facilities, regardless of the form of organization orownership. Please see the Department's website for the current fee structure.

The application process is normally completed within 120 days. The 120 days beginswhen an application packet is determined to be complete. To prevent delays, be sure that all the required documentation is completed, properly signed, with original signatures, dated, and submitted in the proper format and sequence, with the appropriate fee. It is recommended that you retain a copy of the completed application packet for yourrecords.

Once you have determined your application is complete, please mail thecompleted application, documentation, and a check or money order, made out to the Departmentof Health Care Services, to cover the appropriate initial application fee, to the followingaddress:

Department of Health Care Services

Substance Use Disorder Compliance Division

Licensing andCertificationSection

PO Box 997413, MS 2600

Sacramento, California 95899­7413

APPLICATIONINSTRUCTIONS

Please follow these instructions carefully and submit your application only after it has been properly completed, the required supportive documentation has been prepared, and the entire packethas been properly formatted.

Applications received by DHCS that do not meet the requirements described in these instructions will be returned to the applicant, minus any fees, without having been reviewed. The review process will not begin until the application meets submission requirements. If your application is returned without having been reviewed, and you decide not to proceed with the application process, DHCS will refund all fees paid.

Please complete all applicable sections of the application. If a line or question does not apply to you, fill the line or question with “N/A.” If an entire section does not apply to your application, place a check mark in the “N/A” box located in the section heading.

You may attach additional documentation if your information does not fit in the appropriatearea; however, the spaces for the requested information must be completed. The application must be complete or the entire packet will be returned to you without review andprocessing.

The application and all supportive documentation must be printed single sided, with 12 point font on 8 1/2" by 11" white paper. Documentation provided by a third party, such as the lease agreementor fire clearance, must be submitted unaltered and in the original format (size, font, color) it was created. When applying for more than one type of service at a time, (i.e. residential licensure and SUD certification of the same facility, or SUD certification only), complete allthe required sections of the application, prepare the supporting documentation (as listed on the following pages), and submit the entire packet at the sametime.

If you are applying for a license and certification at the same time, please completeone application and submit one set of supportingdocumentation.

SUPPORTING DOCUMENTATION AND DESCRIPTIONS

Due to DHCS’s filing requirements, applications should not be doubled sided, bound, and must not include plastic sheet or page protectors. Each item, as listed below, must be numbered and separated by correspondingly numbered tabbed dividers.

In order to expedite the application process for all applicants, packets not submitted in this order will be rejected without review.

Tab 1 (all applicants) – Initial Treatment Provider Application, Form DHCS 6002 (Rev.06/16).

Tab 2 (all applicants) – Corporations, LLP's, or LLC's must attach their approved articles of incorporation; partnerships must attach the partnership agreement; non­profit organizationsmust attach a copy of the 501(c)(3) filing from the California Secretary of State; sole proprietorsmust attach the Sole Proprietor Supplement. A fictitious business name statement or business licenseis required if the sole proprietor name is different from the name of the facility (see Section Hof instructions).