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How to use or fill out APPROVED TREATMENT PROVIDER PROGRAM APPLICATION
- Click ‘Get Form’ to open the APPROVED TREATMENT PROVIDER PROGRAM APPLICATION in our editor.
- Begin by filling out the 'AGENCY/NAME' and 'TYPE OF AGENCY' sections. Choose from options like Corporation, Individual, Proprietor, or Other.
- Provide your contact information including 'ADDRESS', 'PHONE', and either your FIN or SS#.
- List all clinicians involved by completing the required fields for each clinician separately, including their name, SS#, DOB, degree, and license number.
- Review the list of treatments/services you wish to apply for. Check all relevant boxes under both Adult and YOS Treatment Programs.
- Complete the section requesting three professional references who can vouch for your qualifications. Include their names, phone numbers, agencies, and addresses.
- Attach any required documents such as proof of insurance and detailed descriptions of your treatment programs before submitting your application.
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