Licensing and Medicaid Certification Unit


14 Central Ave.
New Castle, DE  19720
302.255.9441



1. PROGRAM INFORMATION

Name of Organization or Parent Company


Street Address


City, State, Zip


Administrator							Telephone Number


Fax Number							Email Address

2.  	The program is applying for Deemed Status under:

3. CARF		JCAHO	

4.   Date of your last accreditation survey:   								

 

5.  Approximate date of your next accreditation survey:   								

              									Month			      Year
  
6. Accreditation Status (e.g. Full Accreditation, Three Year Accreditation etc…)  						


* If more than one program is accredited under this certificate, please provide the programs names, addresses, names of administrators, phone numbers and email addresses for each on a separate attachment.  


7. If your program is the first program requesting Deemed Status under you organization’s accreditation, please submit the following documents with your Deemed Status Application:

a. A copy of your most current accreditation certificate

b. A copy of your most recent accreditation survey report

c. A copy of your response for corrective action based on your most recent accreditation survey report


8. Have these documents been submitted by another program within your organization prior to this application?  Y / N        If “yes” please provide information on the name of the program and date of the initial submission.  
            																	

9. If more than one program is accredited under the same certificate, are all documents being submitted valid for each program? Y / N.              If “no” please list other documents for your specific program with copies of each.  Include these under a separate attachment.

Please submit all documents at least 90 days prior to the expiration of your current license to:

			Frann S. Anderson, LCSW, CADC
			Unit Director; Licensing and Medicaid Certification Unit
			Fernhook Building; Rm. 12
			14 Central Avenue
			New Castle, DE  19720
			PH:   302.255.9441      FX:   302.255.4999      
			Email: Frann.Anderson@state.de.us