Developmental Services - Case Management

Application in Microsoft Word* or Adobe PDF*

Application for Certification As Provider Of Section 13.05, Targareted Case Management Services

Date: ______________

Name Of Applicant Agency: ______________________________________________________________

Physical Address: Mailing Address: (if different)

____________________________________   _______________________________________

____________________________________   _______________________________________

____________________________________   _______________________________________

Corporation Name/Address (if different): ______________________________________________

______________________________________________

______________________________________________

County _____________________________________

Social Security # Or Employed ID #: _____________________________________________

Name/Title Of Program Administrator ________________________________________

Phone # __________________ FAX # _________________ Email __________________________

Name Of Contact Person: ________________________________________________________

Phone # __________________ FAX # _________________ Email __________________________

Name Of Chief Administrative Officer: __________________________________________

 

I/We have received and read the rules for the certification process. I/We have attached copies of all material required to demonstrate compliance with the certification application process. I/We understand that certification is necessary to become an approved provider of services under MaineCare Manual Section 13.05 (10-144 CMR Ch 101, Section 13). I/We understand that this application authorizes representatives of the Department of Health and Human Services and the State Fire Marshal’s Office (if applicable) to make such visits and inspections as may be necessary to ensure that the facility is in compliance with the laws pertaining to the operation of such facilities.

I/We also understand that the signing of this application effectively serves as a release of information and gives permission to the Department of Health and Human Services to obtain any criminal or protective records information which may be on file in any Country, State or Federal Office.

I/We further certify that all information contained in this application is complete and accurate.

Signatures Required:

__________________________________________________ Date: ___________________________
Applicant/Operator/Administrator

______________________________________
Type or Print Name

__________________________________________________ Date: ___________________________
2ND Applicant (If Applicable)

_______________________________________
Type or Print Name

__________________________________________________ Date: ___________________________
Board President (If Applicable)

_______________________________________
Type or Print Name

For BDS Use Only

Application Received ___________________________________________________________

Initial Review By ________________________________________________________________
Name Date

Note Requests For Additional Information On Separate Sheet and Attach To This Application. Describe Information Requested and Date Requested, Reason, Person and Date Contacted, Response.

Policies Reviewed and Approved By ___________________________________________
Name Date

Certification Granted ______________________
Date

Signature of BDS Representative_____________________________________________