APPROVED TREATMENT PROVIDER PROGRAM APPLICATION: Fill out & sign online

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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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