Services mental health clinic application 2026

1. Click ‘Get Form’ to open the services mental health clinic application in the editor.
2. Begin by entering the date of application completion and the facility name in the designated fields.
3. Fill in your certification number, county, and main office address, including city, state, and zip code.
4. Provide contact information for a designated person at your clinic, including telephone number, fax number, website, and email address. Indicate if this information may be published in the provider directory.
5. If applicable, attach DQA form F-00191 for any branch offices you wish to request. Ensure all required policies are completed before submission.
6. Review each section carefully to ensure compliance with DHS standards and sign where indicated to attest that all statements are correct.

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