DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 
APPLICATION FOR CERTIFICATION 
AS A 
MEDICAID PROVIDER 
INSTRUCTIONS FOR APPLICATION 
1. Prior to completing the enclosed application form, Provider Certification Manual 
Standards should be carefully studied. Unless otherwise waived, programs shall 
comply with these standards. 
2. The application should be largely self-explanatory. The following points should 
be noted: 
  CORPORATE NAME: The full legal name of the program must be used. 
  PROGRAM NAME: The full official title of the program must be used. 
  ADDRESS: Give the full address of the program’ headquarters. 
If the program uses more than one facility, provide 
on a supplemental sheet the addresses of facilities 
used. 
  TELEPHONE: Give the telephone number of the program’s 
headquarters. If more that one facility is used, 
indicated the other phone numbers on a 
supplemental sheet. 
  NOTE: It is important that the information on this 
application is complete, accurate and up to date. 
3. QUESTIONS OR CONCERNS SHOULD BE DIRECTED TO the Licensing and 
Medicaid Certification Unit, Division of Substance Abuse and Mental Health @ 
255-9441. 
STATE OF DELAWARE 
DEPARTMENT OF HEALTH AND SOCIAL SERVICES 
DIVISION OF SUBSTANCE ABUSE AND MENTAL HEALTH 
1901 N. DuPont Highway 
New Castle, DE 19720 
APPLICATION FOR CERTIFICATION 
AS A 
MEDICAID PROVIDER 
DATE OF APPLICATION: ________________________________ 
Check One: 
. INITIAL APPLICATION 
. RENEWAL APPLICATION 
I. PROGRAM IDENTIFICATION 
A. NAME: _______________________________________________________ 
B. ADDRESS: ____________________________________________________ 
______________________________________________________________ 
________________________________________ ZIP CODE: ___________ 
C. TELEPHONE: Area Code (____) Number: ______________ 
D. Type of Program Certification for which application is being made. Check 
appropriate box or boxes: 
. Community Continuum of Care Program (CCCP) 
. Alcohol and Other Drugs (AOD) Day Treatment Program 
. Other (specify) __________________________________________ 
E. Anticipated date of eligibility for certification: _____________________ 
F. IS THE PROGRAM CURRENTLY: 
. Licensed By Whom? _________________ Expiration Date: _______ 
. Certified By Whom? _________________ Expiration Date: _______ 
. Accredited By Whom? _________________ Expiration Date: _______ 
G. PROGRAM MANAGEMENT 
1. NAME OF EXECUTIVE OFFICER: _____________________________ 
TITLE: _____________________________________________ 
ADDRESS: __________________________________________________ 
_____________________________________ ZIP CODE _______________ 
2. NAME OF CONTACT PERSON: _______________________________ 
(If other than Executive Officer) 
TITLE: ____________________________________________________ 
ADDRESS: _________________________________________________ 
__________________________________ ZIP CODE _______________ 
All of the following information shall be submitted with the initial application form. 
Items highlighted by ® should be submitted when applying for recertification. 
. Programs services to be provided. ® - Only if there are changes since last certification 
. Manual of policies and procedures in administrative, financial, personnel and program 
services management. ® Only those policies and procedures which have been updated 
. Program organization chart. ® Only if there are changes since last certification 
. Samples of any forms used by the program and instructions for each form 
. Sample client chart. ® Only if chart has changed since last certification 
. Corporate and/or Advisory Board By-laws. ® Only if there has been a changes since 
last certification. 
. Staff and Board meeting minutes for the six months prior to the submission of this 
application ® 
. Documentation of any current insurance policy coverage such as fire, program and 
clinician liability, etc. ® 
. Documentation of facility occupancy permit 
. Most recent annual audit report to include sources of funding 
_________________________________ ______________________________ 
President of Governing Body/ Program Director 
Advisory Council 
_______________ _______________ 
Date Date 
H. STAFF 
NOTE: Attach additional sheets if necessary. 
NAME TITLE DEGREE 
OR 
CERT. 
MAJOR 
FIELD OF 
STUDY 
YRS OF 
EXP. 
RELATED 
TO 
POSITION 
FULLTIME 
PARTTIME 
CONSULTANT CLINICIAN 
STATUS 
I. GOVERNING BOARD AND/OR ADVISORY COUNCIL 
. GOVERNING BOARD 
. ADVISORY BOARD 
NOTE: Indicate any relationship between a Board Member and a Staff member. Also, indicate Consumer with “C” after name and Family Member with “F” 
after name. Attach additional sheets, if necessary. 
NAME ADDRESS OCCUPATION