FACILITY AGENCY APPLICATION 2026

1. Click ‘Get Form’ to open the FACILITY AGENCY APPLICATION in the editor.
2. Begin by filling out the 'Organizational Facility Identifying Information' section. Enter the legal name, parent company (if applicable), DBA name, and administrative address along with contact details such as phone, fax, email, and website.
3. In the 'Identify Levels of Care' section, select the appropriate levels of care your facility desires to contract. Ensure you check all relevant options for substance use disorder and mental health services.
4. Complete the 'Organizational Provider Contact Information' by providing names and contact details for key personnel including primary contacts and administrators.
5. Fill in the accreditation and licensure sections accurately. Attach any required documentation directly through our platform for a seamless submission process.
6. Review all entries for accuracy before signing at the end of the application. Ensure that you certify that all information is complete and true.

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