Attachment D: New Opioid Programs



Licensing and Medicaid Certification Unit
APPLICATION FOR NEW OPIOID TREATMENT PROGRAMS


14 Central Ave.
New Castle, DE  19720
302.255.9441



1. Please attach a list of all Opioid Treatment programs within your organization including:  The name of the preferred contact at each program, address, phone number, fax number and email address.  Please provide this information under separate attachment.  

2. Please provide the name and documentation of all credentials (e.g. licenses) for all medical staff that will be working with Opioid patients at the program for which you are seeking licensure:

a. Medical Staff

i. ______________________________________________________         
   Medical Director		 License Expiration Date










b. Other Prescribing, Professional Medical Staff:

  Name					       License/ Expiration Date

















c. Nursing Staff:

Name					License/Expiration Date

































3. Medication Dispensing days and Times 

Day					   Times

Sunday	 						

Monday   							

Tuesday							

Wednesday						

Thursday							
 
Friday							

Saturday							

Sunday							

    

4. Please attach copies of the organization’s protocols and procedures for Take Home and Detoxification.  

5. Please attach copies of the organization’s protocols for assuring adequate procedures to identify theft or diversion of Opioid antagonist medication.

6. Please attach the substantiated need for your program as required in Section V of the Application For Licensure “For Initial Applicants.”   

7. Please explain how you will collect fees from OTP consumers and the process by which you will provide continuity of care for consumers who are unable to pay for services.  Include the projected number of individuals you will refer to DSAMH funded programs within the first year of providing services and documentation of how your projections were estimated.



8. Referral to Community Programs

a. Please attach letters of agreement from community programs that you intend to refer consumers to.  Include referral sources for Mental Health treatment, DUI treatment, DSAMH funded OTP programs and any other referral source you anticipate developing a relationship with.

9. Safety and Security

a. Please explain the program’s plans for assuring adequate on and off site security measures to ensure the safety of patients, staff and business and residential neighbors.


Please include ATTACHMENT D with your initial application for licensure and send 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