Fillable Check only one: DHS Form #5 New application (State of Arkansas)

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Check only one: DHS Form #5 New application (State of Arkansas)

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File type: PDF

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Division of Provider Services and Quality Assurance
NOTIFICATION REGARDING CERTIFICATION
INDEPENDENTLY LICENSED PRACTITIONER
Completed forms should be submitted to DPSQA.ProviderApplications@dhs.arkansas.gov.
Page 1 of 2 Revised 5/24/2021
Check only one: ☐DHS Form #5 – New application for certification/Adding site
☐ DHS Form #3 – Application to renew certification; Cert. #
Duration
☐ DHS Form #4 – Application for site transfer; Cert. #
☐ DHS Form #4 – Site closure; Cert
. #
☐ Notification for site relocation; Cert. #
☐ DHS Form #6 – Annual Report; Cert. #
PROVIDER NAME:
PROVIDER ADDRESS:
Street
City
County
State
MAILING ADDRESS:
(if different)
Street
City
County
State
☐ Licensed Certified Social Worker (LCSW) ☐Licensed Psychologist
☐ Licensed Marital and Family Therapist (LMFT) ☐Licensed Professional Counselor
☐ Licensed Psychological Examiner – Independent (LPE-I)
CONTACT NAME:
CONTACT E-MAIL ADDRESS: PHONE NUMBER:
TAXPAYER ID # (TIN or EIN): HOURS OF OPERATION:
The applicant affirms receipt of the Behavioral Health Independently Licensed Practitioners Certification Manual
and agrees to comply with these standards, as indicated by the signature below:
Name of Applicant (print)
Signature of Applicant Date
click to sign
signature
click to edit
Division of Provider Services and Quality Assurance
NOTIFICATION REGARDING CERTIFICATION
INDEPENDENTLY LICENSED PRACTITIONER
*Additional information may be requested and required upon review of application(s) for license.
Page 2 of 2 Revised 5/24/2021
Please remit with the form the following documents:
DHS Form #5 – New application for certification/Adding site:
• Completed W-9 in Practitioners name
• Any required business license(s)
• Copy of current practitioner license
• Copy of Family Involvement Policy (for clients under age 18)
DHS Form #3 – Application to renew certification:
• Copy of current practitioner license
• Copy of current required business license(s), if any
• Copy of Family Involvement Policy (for clients under age 18), if changed
DHS Form #4 – Site closure:
• Documentation demonstrating continuity of care
• Documentation of notice to families and clients of closure
• Copy of public notice to be posted on site entry
• Copy of transition plan
DHS Form # 4 (continued) – Application for site transfer:
• Any required business license(s) for proposed location
• Copy of current practitioner license
• Copy of Family Involvement Policy (for clients under age 18), if changed
Notification for site relocation:
The provider must follow the rules for closing the original site, and the rules for opening a new site.
DHS Form # 6 – Annual Report:
• Copy of current practitioner license(s)
• Copy of existing contracts with professionals, agencies, and entities
• Copy of passed annual fire and safety inspection from the State Fire Marshall/local authority
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Check only one: DHS Form 5 New application (State of Arkansas)

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Completed 12 November 2021

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