Dbhds Application Details

The VirginiaProviderApplicationForm.com website was created to provide an easy-to-use resource for individuals seeking information about the application process for providers in the state of Virginia. The website includes detailed information about each step of the application process, including eligibility requirements and submission guidelines. In addition, visitors can find contact information for key government agencies involved in the provider approval process.

You will find more information relating to the virginia provider application by looking through the table our team put together.

QuestionAnswer
Form NameVirginia Provider Application
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesdbhds virginia forms, virginia provider application form, virginia provider application, dbhds initial application

Form Preview Example

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:____________

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REQUIRED ATTACHMENTS

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

4

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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