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Form Name	Virginia Provider Application
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	dbhds virginia forms, virginia provider application form, virginia provider application, dbhds initial application

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Virginia Department of Behavioral Health & Developmental Services

INITIAL PROVIDER APPLICATION FOR LICENSING

Code of Virginia §37.2-405 & §35-46

Please use a typewriter or print legibly using permanent, black ink. The chief executive officer, director, or other member of the governing body who has the authority and responsibility for maintaining standards, policies, and procedures for the service may complete this application.

1.APPLICANT INFORMATION: Identify the person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service:

Organization Name:_____________________________________________________________________________________

Mailing Address________________________________________________________________________________________

City:__________________________ County __________________________________State:___________________________

Zip:___________________ Phone:( )___________________________ Email:_________________________________

Names of all Owners and the percentage (%) of the organization owned by each _____________________________________

___________________________________________________________________________________________________________

Chief Executive Officer or Director. Identify the person responsible for the overall management and oversight of the service(s) to be operated by the applicant.

Name:____________________________________________Title:_______________________________________________

Phone:( )___________________ Fax Number:( )___________________ E-mail:____________________________

All Residential Services: (The liaison is the staff that shall be responsible for facilitating cooperative relationship with neighbors, the school system, local law enforcement, local government officials and the community at large.)

Community Liaison Name: _________________________ Phone ( )_______________ E-mail _____________________

2.ORGANIZATIONAL STRUCTURE: Identify the organizational structure of the applicant’s governing body.

Check one(1) of the following:		Check one(1) of the following:
[] Non-Profit	[] For-Profit	[] Individual (proprietorship)	[] Partnership
		[] Corporation	[] Unincorporated Organization or Association
		Public agency:
		[] State [] Community Services Board	[] Other _________________________________

Identify accrediting or certifying organization from the following, if applicable:

[] Accreditation Council for Services for People with Developmental Disabilities	[] Virginia Association of Special Education Facilities
[] Joint Commission on Accreditation of Health Care Organizations	[] Other associations or organizations:
[] Commission on Accreditation of Rehabilitation Facilities	_________________________________________

3.APPLICANT PARENT COMPANY INFORMATION: Identify the parent company of person, partnership, corporation, association, or governmental agency applying to lawfully establish, conduct, and provide service:

Company

Name:_______________________________________________________________________________________________

Mailing Address:______________________ _____City:_____________ County: _____________________ State:_____________

Zip:___________ Phone:( )__________________________ E-mail:_______________________________________________

Name:___________________________________________________Title:_______________________________________

SERVICE TYPE:

Place a check to identify the service type. If the service type is not listed, please note in the service information section. Please note new applicants (no independent service operation experience) are permitted to apply for ONE service on the initial application.

Check
one	Service	Pgm	Description	Licensed As Statement
				A Level C mental health children's residential service for children with serious
	14	001	Level C MH Children Residential Service	emotional disturbance

				A Level C mental health children's residential service for children with serious
	14	001	Level C MH Children Residential Service	emotional disturbance
				A mental health children's residential service for children with serious emotional
	14	004	MH Children Residential Service	disturbance
	14	007	SA Children Residential Service	A substance abuse children's residential service for children

				A mental health group home residential service for children with serious emotional
	14	008	MH Children Group Home Residential Service	disturbance
	14	033	SA Children Group Home Residential Service	A substance abuse group home residential service for children
	14	035	DD Children Group Home Residential Service	A developmental disability group home residential service for children

				An intermediate care facility for individuals with a developmental disability (ICF-IDD)
	14	048	ICF-IDD Children Group Home Residential Service	group home residential service for children

				A residential group home with crisis stabilization REACH service for children and
				adolescents with a co-occurring diagnosis of developmental disability and behavioral
	14	59	REACH Children’s Residential Service	health needs

10/6/17 DBHDS

5.SERVICE INFORMATION: Complete for the organization to be licensed by the Department of Behavioral Health and Developmental Services.

Service Director: __________________________________________________________________________________

Phone: (	) ________________________________________ E-
Mail_____________________________________
Client Demographics (check all that apply):
[] Male	[] Female [] Both	[] Child	[] Adolescent (Min. & Max. Age Range) _____________ [] Adult

LOCATION

6.Location Name__________________________________________# of beds:_______________________________

Address:___________________________________________________________________________________________

City:_____________________ County: _____________________ State:________________ Zip:___________________

Location Manager:________________________________ Phone:( )______________ E-

mail:____________________

Directions:_________________________________________________________________________________________

7. NAME AND ADDRESS OF OWNER OF PHYSICAL PLANT

Name

Address

8. RECORDS: IDENTIFY THE LOCATION OF THE FOLLOWING RECORDS

Financial Records

Address: ________________________________________City:___________________ County ___________________

State:________________ Zip:____________

Personnel Records

Address: ________________________________________City:___________________ County ___________________

State:________________ Zip:____________

Residents’ Records

Address: ________________________________________City:___________________ County ___________________

State:________________ Zip:____________

	REQUIRED ATTACHMENTS	Children’s Residential Service
		Children’s Residential Service	All Other Services
		Regulations	Regulations

1.	⁭ The Completed Application form	§12 VAC 35-46-20 (D)(1)	§35-105-40(A)
2.	⁭ A Working Budget (appropriated revenues and projected	§12 VAC 35-46-20 (D)(1)	§35-105-40(A)(1)
expenses for one year –a 12-month period)		§12 VAC 35-46-190 (A)(2)
3.	⁭ Evidence of financial resources or line of credit sufficient to	§12 VAC 35-46-180	§35-105-210(A) &
cover estimated operating expenses for ninety days (and must be			§35-105-40(A)(2)
maintained on an ongoing basis)
4.	⁭ A copy of the Organizational Structure, showing the	§12 VAC 35-46-20 (D)(1)	§35-105-190(B)
relationship of the management and leadership to the service		& §12 VAC 35-46-20 A

5.	⁭ Complete Service Description (including philosophy and	§12 VAC 35-46-20 (D)(1)	§35-105-40 & §580(C),
objectives of the organization, comprehensive description of population			§570
to be served, admission, exclusion, continued stay,
discharge/termination criteria, a description of services or interventions
to be offered, brochures, pamphlets distributed to the public, a copy of
the proposed program schedule, etc)
6. ⁭ Record Management Policy addressing all the requirements of		§12 VAC 35-46-20 B [1-5]	§35-105-40 & §870(A),
the regulation		§12 VAC 35-46-180. C	390

7.	⁭ Staffing Schedule & Written Staffing plan (use staff	§12 VAC 35-46-180	§35-105-590
information sheet to list potential staff members with designated
positions & qualifications, etc.), relief staffing plan, & comprehensive
supervision plan
8.	⁭ Resumes of all identified Staff, particularly services director,	§12 VAC 35-46-270 (B)(1)	§35-105-420(A)
QIDP, QMHP, and licensed personnel.
9.	⁭ Position Descriptions- copies of all position(job) descriptions	§12 VAC 35-46-20 (D)(1)	§35-105-40 & §410(A)
that address all the requirements (position descriptions for case		§12 VAC 35-46-280,
management, ICT and PACT services must address the additional		§12 VAC 35-46-340 &
regulations for those services).		§12 VAC 35-46-350
10. ⁭ Evidence of Authority to conduct Business in Virginia.		§12 VAC 35-46-20 (D)(1)	§35-105-40(A)(3) and
Generally this will a copy of the applicant’s State Corporation		& §12 VAC 35-46-320	§190(B)
Commission Certificate.
11. ⁭ Certificate of Occupancy – for the building where services are		§12 VAC 35-46-20 (D)(1)	§35-105-260
to be provided (except home-based services),
	AND FOR RESIDENTIAL SERVICES:
1.	⁭ Copy of the Building floor plan, with dimensions	§12 VAC 35-46-20 (D)(1)	§35-105-40 (B)(5)
13.⁭ Current Health Inspection		§12 VAC 35-46-20 B	§35-105-290

14. ⁭ Current Fire Inspection		§12 VAC 35-46-20 (D)[1-4]	§35-105-320

Children’s Residential Service Only
15. ⁭ Articles of Incorporation, By- laws, & Certificate of		§12 VAC 35-46-20 (D)(1)	Facility operated by a
Incorporation			VA corporation
16⁭ Articles of Incorporation, By- laws, & Certificate of Authority		§12 VAC 35-46-20 (D)(1)	Facility operated by a
			out of state corporation
6. .⁭ Listing of board members, the Executive Committee, or public		§12 VAC 35-46-20-170	Facilities with a
	agency all members of legally accountable governing body		Governing Board
7.	⁭ References for three officers of the Board including President,	§12 VAC 35-46-20 D	Facility operated by
	Secretary and Member-at-Large		Corp., an
			unincorporated
			Organization, or an
			Association

Current/Past Provider Services

Please identify:

1)The legal names and dates of any services licensed in Virginia or other states that the applicant currently holds or has held,

2)Previous sanctions or negative actions against any licensed to provide services that the holds or has held in any other state or in Virginia, and

3)The names and dates of any disciplinary actions involving the applicant’s current or past licensed services. If none, please indicate, “NONE” in the space below.

Current Services:

_____________________________________________________________________________________________

Past Services:

_____________________________________________________________________________________________

Sanctions/Negative Actions/Disciplinary Actions:

_____________________________________________________________________________________________

Certificate of Application

This certificate is to be read and signed by the applicant. The person signing below must be the individual applicant in the case of a proprietorship or partnership, or the chairperson or equivalent officer in the case of a corporation or other association, or the person charged with the administration of the service provided by the appointing authority in the case of a governmental agency.

I am in receipt of and have read the applicable rules and regulations for licensing. It is my intent to comply with the statutes and regulations and to remain in compliance if licensed.

I grant permission to authorized agents of the Department of Behavioral Health and Developmental Services to make necessary investigations into this application or complaints received.

I understand that unannounced visits will be made to determine continued compliance with regulations.

TO THE BEST OF MY KNOWLEDGE AND BELIEF, ALL INFORMATION CONTAINED HEREIN IS CORRECT AND COMPLETE. I FURTHER DECLARE MY AUTHORITY AND RESPONSIBILITY TO MAKE THIS APPLICATION.

Signature of Applicant:_______________________________________Title:______________________

Date:_________________

If you have any questions concerning the application, please contact this office at (804) 786-1747. Please return the completed application to:

Office of Licensing

Department of Behavioral Health and Developmental Services

Post Office Box 1797

Richmond, Virginia 23218-1797

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