Mn Rule 29 Form – Fill Out and Use This PDF

State of Minnesota

Department of Human Services

Division of Licensing

Minnesota Statutes, Chapter 245.69, subdivision 2

Minnesota Rules, parts 9520.0750 through 9520.0870

Application for Rule 29 certification

(Mental Health Centers and Clinics for insurance and contract reimbursement)

Name of program:

Address of program:

City:	State:	Zip:	County:
Telephone number:	Fax number, if applicable:
Name of contact person:	Telephone number for contact person:

Do you hold other program/service licenses issued by the Department of Human Services? Yes___ No___

If yes, please provide the name of the program, the license number, location and type of service on a separate sheet

Have you ever had a license denied or revoked? Yes___ No___

If yes, please provide the name of the program, the license number, location and type of service, and the date of the action on a separate sheet.

Note:

Pursuant to Minnesota Rules, part 9520.0820, subpart 1, the application must be made on the forms and in the manner prescribed by the commissioner. The Licensing Division will not process an application before the application fee is paid.

Send the application fee and completed application to:

DHS License – Deposit Code 150

Initial License Application

PO Box 64837

St. Paul, MN 55164-0837.

Following the check list of requirements, there are links to -- or copies of -- the relevant Minnesota Rules and Statutes.

Forms to be completed and submitted by all applicants

Completed? Form

License Application Fee Payment Form

Program Location and Contact Information

Certification laws and rules

The following laws and rules are enclosed for your reference:

A. Minnesota Rules, parts 9520.0750 to 9520.0870 (DHS Rule 29)

B. Minnesota Statutes, section 245.69

Application process

•An application will not be considered complete until all required information has been submitted and determined to be in compliance with the laws and rules.

•If an application includes policies and procedures that are determined to be not in compliance with the applicable laws and rules, the application will be considered incomplete and a list of problems will be provided to the applicant with instructions for correction. A time limit for correction will be specified.

•Failure to submit a complete application within the specified time will result in license denial and the license fee will be forfeited.

•Within 90 days after receipt of a completed application (when everything has been submitted and determined to be in compliance), including all necessary approvals from other authorities, you will be informed whether your application has been approved or denied.

•If your certification is denied, you will be informed at that time of your right to contest the denial.

•After a certificate is issued, the Licensing Division will conduct periodic licensing reviews, including complaint investigations.

Subsequent annual fee

Rule 29 certificates are effective from Jan. 1 to Dec. 31 of each calendar year. The application fee is considered the certification fee for the calendar year in which the application is approved. Certificates are re-issued annually and certificate holders must submit payment for the certificate when invoiced in order for their certification to remain effective. See the fee schedule in Minnesota Statutes, section 245A.10, subdivision 5 (b).

Requirements specific to Rule 29 applicants

•The following lists include required forms, policies and reports to be submitted for the application to be considered complete.

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•Each item on the following lists must accompany the Application for Rule 29 certification.

•Return the checklists with the application, showing the name or other identifier of the document that contains the required information. (Examples of document identifiers include “Policy and Procedures Manual, page xx” or “Application attachment x”)

•Keep a copy of the completed check list for your records.

Program policies and procedures to be submitted with the application

Item	Law or rule requirement	Description	Identifier
A.	Minnesota Rules, part 9520.0770,	Purposes of the Center
	subpart 2
B.	Minnesota Rules, part 9520.0770,	Governing body’s source of
	subpart 3	authority
C.	Minnesota Rules, part 9520.0770,	Chart or statement of
	subpart 4	organization
D.	Minnesota Rules, part 9520.0790,	Multidisciplinary approach
	subpart 1	documentation
E.	Minnesota Rules, part 9520.0790,	Intake and case assignment
	subpart 2	procedures
F.	Minnesota Rules, part 9520.0790,	Assessment and diagnostic
	subpart 3	process
G.	Minnesota Rules, part 9520.0790,	Standards for case review
	subpart 6
H.	Minnesota Rules, part 9520.0790,	Documentation of access to
	subpart 9	inpatient care
I.	Minnesota Rules, part 9520.0800,	Policies and procedures
	subpart 2	regarding peer review
J.	Minnesota Rules, part 9520.0800,	Policies and procedures
	subpart 3	regarding internal utilization
		review
K	Minnesota Rules, part 9520.0800,	Procedure for clinical evaluation
	subpart 4	and supervision
L.	Minnesota Rules, part 9520.0800,	Procedures for reporting and
	subpart 6	investigating violations of
		standards and policies
M.	Minnesota Rules, part 9520.0800,	Procedures for reporting abuse
	subpart 6	or neglect
N.	Minnesota Rules, part 9520.0810	Complete the staffing
		information form provided with
		this application

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Additional documentation to be submitted by centers or clinics with satellite locations

Law or Rule Requirement	Description	Identifier
Minnesota Rules, part 9520.0780,	Complete the satellite location form
subpart 1	provided with this application
Minnesota Rules, part 9520.0780,	Policies for the operation of the satellite
subpart 1	locations

This information is available in other forms to people with disabilities by contacting the Licensing Division at

(651)296-3971 voice. TTY/TDD users can call the Minnesota Relay at 711 or (800) 627-3529. For the Speech- to-Speech Relay, call (877) 627-3848.

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Rule 29 Certification Agreement

The applicant mental health center or mental health clinic seeking approval pursuant to Minnesota Statutes, section 62A.152 from the Commissioner of the Department of Human Services (DHS) understands that approval shall be based upon conformance to Minnesota Rules, parts 9520.0750 through 9520.0870 and Minnesota Statutes, section 245.69, subdivision 2. The applicant understands that the approval means eligibility for insurance reimbursement as a clinic or center pursuant to Minnesota Statutes, section 62A.152 only; approval shall not be construed as endorsement or accreditation by DHS, nor entitle the applicant to any other reimbursement or privilege. It is agreed that the approval procedure will require the applicant to submit a completed application form and the prescribed fee.

The department will review the application and conduct an on-site review for compliance with Minnesota Rules, parts 9520.0750 through 9520.0870 and Minnesota Statutes, section 245.69, subdivision 2. The applicant will receive written notice of the commissioner's decision. If the applicant is found by the commissioner to be in noncompliance and the application is disapproved, the applicant will be afforded the opportunity to appeal in accordance with Minnesota Statutes, Chapter 14. The applicant agrees that the department is solely responsible for approval or nonapproval of a mental health center or clinic under said rule, and the applicant's rights, remedies, and grievances shall exist exclusively against the department.

The applicant is responsible for reporting to the Commissioner any changes during the approval period in staffing, treatment, or quality assurance standards which affect the applicant's compliance with Minnesota Rules, parts 9520.0750 to 9520.0870 or Minnesota Statutes, section 245.69, subdivision 2. The applicant attests that the information included within the application is complete and correct. Documentation of compliance will be maintained at the center or clinic and be available for departmental review.

_________________________________

Chairman of the Governing Body

________________________________

Executive Director

_______________________________

Agency Mental Health Coordinator

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Satellite/Secondary locations

INSTRUCTIONS:

Clinic/Center Name: As it appears on the certificate

Satellite Location Name: Provide the name commonly recognized in the community for this location (examples—ABC Clinic West; All Saints Church)

Address: Street address, use as many lines as necessary

Available Mental Health Professional: Individual identified in compliance with Minnesota Rules part 9520.0780, item E

Clinic/Center Name

License/Certificate Number

Satellite Locations

Location #1

Name

Address, Line 1

Address, Line 2

City, State, Zip

Available mental health professional

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Location #2

Name

Address, Line 1

Address, Line 2

City, State, Zip

Available mental health professional

Location #3

Name

Address, Line 1

Address, Line 2

City, State, Zip

Available mental health professional

Please copy this form as necessary to report all locations

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