Fillable Prior Consultation Form 1A Certification Proposal - Prior Consult - Attachment 1A (05/14)

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Prior Consultation Form 1A Certification Proposal - Prior Consult - Attachment 1A (05/14)

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S
NEW YORK STATE
OFFICE OF ADDICTION SERVICES AND SUPPORTS
Certification Proposal – Prior Consult
Attachment 1A
This form must include Local Government Unit (LGU) and Regional Office (RO) signatures. Include this form
with submission of the Certification Application (PPD-5) as proof of prior consultation with the LGU
and RO. Please note that this document is not an application.
Section 1 Entity/Administrative Information
Applicant’s Legal Name (Existing Entities Only) Proposed Name (If proposal involves a new entity or a name change)
Building/Building # Room/Suite Floor PO Box or Postal Route
Street Address
City Town Village
State Zip Code + 4 Telephone Number (including Area Code)
E-Mail Address Fax Number (including Area Code)
Section 2 Proposal Information
Check the box(es) that identifies the proposed action(s).
New OASAS Provider
New Sponsor
New Treatment Service
Capacity Increase
Relocation
pace Expansion
Additional Location
Merger
Transfer of Ownership
Change in Ownership
Service Identification
Identify the new service(s) to be provided. Regulatory requirements for chemical dependence services can be found on the
OASAS website at the following link: http://www.oasas.ny.gov/regs/index.cfm.
Briefly describe the action/service proposed.
Attachment 1A (03/17)
Page 1 of 5
Please describe outreach to the local community (e.g., Community Service Boards, Community Boards, Planning Boards,
Neighborhood Coalitions, other local municipalities). Please summarize community input, including any existing or likely
community concerns, as well as any recommendations. Include date(s) and the name(s) of the local community official(s).
Site and Staffing – Describe the location, including the address (if known) of each of the services proposed, the geographic
or political boundaries of the area to be served, the need for the proposed service(s) in the service area, and the proposed
staffing pattern for each service proposed.
Description of Services - Describe the approach/philosophy regarding the treatment of chemical dependence, including
use of self-help services, medication, individual/group counseling, and other treatment techniques. (To be completed only
by entities that are not currently authorized to provide OASAS treatment services.)
Attachment 1A (03/17)
Page 2 of 5
Section 3 Entity Status
Current Type of Entity Proposed (If proposal includes a change in type of entity)
Individual Proprietorship Individual Proprietorship
Partnership Partnership
Limited Liability Partnership Limited Liability Partnership
Not-for-Profit Corporation Not-for-Profit Corporation
Business Corporation Business Corporation
Limited Liability Company Limited Liability Company
State Agency State Agency
County Department/Agency County Department/Agency
Municipal Department/Agency Municipal Department/Agency
Public Benefit Corporation Public Benefit Corporation
Other (Specify) Other (Specify)
Current Entity Relationship to OASAS
New Entity (see below) Existing Non-OASAS Entity (see below) OASAS Entity OASAS Provider No.
To Be Completed
by New Entities
and by Existing
Non-OASAS
Entities Only
Entity Licenses, Certifications and Accreditations – Check each license, certification and/or accreditation held
(include out-of-state licenses, etc. in “Other”
NYS Office of Mental Health NYS Office for People with Developmental Disabilities
NYS Department of Health NYS Office of Family and Children’s Services
NYS Department of Education The Joint Commission
Other (specify)
Entity Experience in Chemical Dependence Services
If the applicant has not been previously certified by OASAS, include as an Attachment a brief
history of the entity’s experience in providing chemical dependence services, including alcoholism
and substance abuse services, along with other human services.
Section 4 Application Contact Person
Name of Contact Person Position/Affiliation with Applicant
Address (Street, City, State, Zip Code + 4)
Telephone Number Fax Number E-Mail Address
Attachment 1A (03/17) Page 3 of 5
Section 5
Site Budget
Prepare this section for each proposed new service at each site.
A.
Revenues
Budget Item Description
Proposed Operating Budget
Pre-Operational Annual
Client/Patient Fees
Temporary Assistance to Needy Families – TANF (formerly AFDC)
Safety Net Assistance – SNA (formerly Home Relief)
Medicaid (Managed Care)
Medicaid (Fee for Service)
Medicare
Private Health Insurance (Managed Care)
Private Health Insurance (Fee for Service)
Congregate Care Benefit Payments
Federal Grants (Other than through OASAS)
State Grants (Other than OASAS)
Local Government Grants
Cash Donations from Closely Allied Entities
Sale of Goods and Services (Sales Contracts/Purchase of Services
Agreements)
Other Cash Resources (List Source and Amounts)
Total Revenues
B.
Expenses
Personal Services (Salaries/Wages)
Personal Services (Fringe Benefits)
Consultants/Professional Services
Equipment to be Expensed
Property Expense
Other Non-Personal Services Expenses
Allocated Provider Administration (Management &
General/Overhead)
Total Expenses
C.
Construction
Estimated Capital Cost
Acquisition
Construction
Renovation
Total Capital Expenses
D.
Profit/(Defici
t)
Total Expenses less Total Revenues
OASAS State Aid
E.
Sources of Deficit
Financing, If Any
Local Government (Tax Levy)
Other Deficit Funding Sources (List Sources and Amounts)
Attachment 1A (03/17)
Page 4 of 5
Section 6 Signatures
Applicant Representative (Print Name)
A
pplicant Representative Signature Date
LGU Representative (Print Name) LGU Representative Signature Date
Recommendation for the provider to submit a Certification Application
LGU Comments
RO Representative (Print Name) RO Representative Signature Date
Recommendation for the provider to submit a Certification
Application RO Comments
Attachment 1A (03/17)
Page 5 of 5
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Prior Consultation Form 1A Certification Proposal - Prior Consult - Attachment 1A (0514)

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Completed 1 May 2020

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