Application Modification Face Sheet

Behavioral Health Administration

COMAR 10.21

Application Modification Face Sheet

Community Mental Health Program

(REV 7-8-17)

Relocation Expansion (check one): Name Change

Location

Service Type

PLEASE PRINT Date:

CURRENT BUSINESS INFORMATION:
Business Name:
Corporate Address (City, State, Zip):
Maryland Charter Info: Department ID:
NOTE: Proof of Good Standing /Active Status must be attached
Medicaid Provider: No Yes MA # / DEA #, if applicable:
Business Operation Days & Hours:
DAY / Monday / Tuesday / Wednesday / Thursday / Friday / Saturday
HOURS / a.m.
p.m. / a.m.
p.m. / a.m.
p.m. / a.m.
p.m. / a.m.
p.m. / a.m.
p.m.
Primary Contact: / Email:
Telephone: () - / Fax: () -
Emergency Contact: / Emergency Telephone:
() -
Designated CSA (county/city):
Please check the type(s) of mental health program that is Relocating/Expanding
ü / Community Mental Health Program / COMAR Chapter
Psychiatric Day Treatment (PHP) / 10.21.02
Group Home for Adults with Mental Illness (GH)
Group Home Capacity: / 10.21.04
Therapeutic Group Home (TGH)
Therapeutic Group Home Capacity: / 10.21.07
Therapeutic Nursery Program (TNP) / 10.21.18
Mobile Treatment Services (MTS) / 10.21.19
Outpatient Mental Health Center (OMHC) / 10.21.20
Psychiatric Rehabilitation Programs for Adults (PRP-A) / 10.21.21
Residential Crisis Services Capacity: / 10.21.26
Respite Care Services / 10.21.27
Mental Health Vocational Program (MHVP) / 10.21.28
Psychiatric Rehabilitation Services for Minors (PRP-M) / 10.21.29
PHYSICAL SITE EXPANSION/RELOCATION ADDRESS INFORMATION
Current Location/Address (if different from above):
Proposed Location/Full Address:
CSA Notified? Yes No
NOTE: (1) The CSA must review & approve the application before submission to BHA. (2) Approval by BHA is required BEFORE operating at the proposed location. Applications for physical site expansion/relocations should be made to BHA 60 days BEFORE site expansion/relocation.
PROGRAM NAME CHANGE
Current Business/Program Name:
Proposed Business/Program Name:
Effective Date of Name Change:
Maryland Dept. of Assessments & Taxation Information: Department ID #
NOTE: Proof of Good Standing or Active Status must be attached

Printed Name & Title Date

______

Signature

REQUIRED ATTACHMENTS:

ALL PROGRAMS REQUESTING MODIFICATION:

· Proof of Good Standing/Active Status with the Maryland Department of Assessments &

Taxation (may be a copy).

· Current Organizational Chart

· Staff Resumes that correspond to Organizational Chart

For PHYSICAL SITE EXPANSION/RELOCATION:

· Use and Occupancy Permit for proposed location*;

· Fire Inspection Report/Permit for proposed location;*

· Verification from the local Core Service Agency (CSA) that that program does not have any outstanding issues; and

· Verification from the local CSA for the proposed location that the CSA has been informed of the relocation/expansion application and the program has expressed a willingness to collaborate with the CSA.

*NOTE: May not be required for residential sites. Please check with your local jurisdiction to confirm.

For SERVICE TYPE EXPANSION:

· Updated Policies and Procedures that reflect the service delivery requirements of the applicable regulatory chapter type is regulated;

· Verification from the local Core Service Agency (CSA) that that program does not have any outstanding issues;

· Verification of all required staff, including program director, rehabilitation specialist, and

medical director, if applicable. Verification should include a signed job description or contact and evidence of current Maryland licensure.

· A Business Plan Information Sheet to include information relative to the new site/new service

Ø Special Outpatient Mental Health Center (OMHC) Review Criteria: An applicant seeking to obtain approval to become and OMHC under COMAR 10.21.20, an OMHC Eligibility Determination Form must be submitted along with the standard application. An OMHC application WILL NOT be considered until an eligibility determination review has been completed by the Behavioral Health Administration. Please note that programs currently approved under other COMAR Title 10, Subtitle 21 chapters for less than 1 year are not eligible to apply.

Ø All applicants who are applying to provide services for children must be registered with CJIS (http://www.dcps.state.md.us/publicservs/bgchecks.shtml) and provide evidence/documentation of this registration.

For PROGRAM NAME CHANGE (does not include change in ownership):

· Proof of Good Standing/Active Status with the Maryland Department of Assessments & Taxation for new name (may be a copy).