Sec.17a-453a-11. Provider application

(a) In order to be considered for participation in the GABHP, a provider shall request in writing an application packet from the designated agent. The application packet shall be completed by the provider and shall include all information required by DMHAS.

(b) DMHAS shall require, at a minimum, the following information from a provider:

(1) Name, address, telephone number and contact person;

(2) Age groups and genders treated;

(3) Staff licenses, competencies and language(s) spoken;

(4) Problems and disorders treated;

(5) Level(s) of care offered and capacity for each;

(6) Treatment specialties; and

(7) A copy of the state-required facility license(s).

(c) The provider shall complete the application and return it to the designated agent not more than thirty (30) calendar days after the date of receipt. If a provider does not submit a completed application within the required time frame, DMHAS, at its sole discretion, may decide not to accept the provider's application.

(Adopted effective December 7, 2009)