Survey Application ORGANIZATION INFORMATION
|
|
- Joella Bennett
- 6 years ago
- Views:
Transcription
1 ORGANIZATION TO BE SURVEYED Survey Application ORGANIZATION INFORMATION Organization/Unit Name Acronym Federal Tax Identification Number La Frontera Inc. Hope Center Hope Center Organization Website (Example: Telephone (Example: ) Fax (Example: ) Street Address (no P.O. Box) 260 South Scott Avenue Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Tucson AZ County/Municipality Pima Country US ORGANIZATION CHARACTERISTICS Total annual operating revenue for the Annual operating revenue for the organization being surveyed programs seeking accreditation Fiscal Year End 9,402,923 1,060,181 06/30 Locale Urban Ownership Type Private, not for profit Type of Government Entity Description Other Ownership Description Other Government Entity Description CORPORATE STRUCTURE 1. Is your organization a unit or department within a larger entity (i.e., not a distinct legal entity and has the same federal tax identification number as the larger entity)? Yes Name of larger entity Street Address (no P.O. Box) Suite Number, Floor, or Department La Frontera Center, Inc. 502 West 29 th Street City State/Province/Territory Zip/Postal Code Tucson AZ Country Briefly describe the larger entity and how your programs fit into its operations. 2. If your organization is a unit or department within a larger entity, is the larger entity a subsidiary of a parent company (i.e., a distinct legal entity with a separate federal tax identification number from the parent company)? 1 of 13
2 Name of Parent Company Street Address (no P.O. Box) Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Country Federal Tax Identification Number 3. If your organization is not a unit or department within a larger entity, is it a subsidiary of a parent company (i.e., a distinct legal entity with a separate federal tax identification number from the parent company)? Name of Parent Company Street Address (no P.O. Box) Suite Number, Floor, or Department City State/Province/Territory Zip/Postal Code Country Federal Tax Identification Number SIGNIFICANT CHANGES/EVENTS Indicate if your organization experienced any significant changes or events in the past year for the programs seeking accreditation. Change/Event Type Yes/ Explanation Change in leadership Change in ownership Relocation of accredited program/service or organization itself Change in mailing and/or addresses Significant reorganization of personnel Expansion, reduction, or elimination of program, service, or site Severe financial distress Merger or consolidation Joint Venture or acquisition involving accredited programs/services Investigations Material litigation Catastrophes Sentinel events CMS Sanctions, bans on admissions, fines, penalties, or loss of programs SOURCES OF FUNDING/REFERRAL Category Funding Referral Name of Funding/Referral Source Managed Care PPO no info Medicaid/MediCal/AHCCCS Medicare 2 of 13
3 OTP organizations must list a State Methadone Authority contact. If your organization is using the CARF-CCAC standards manual as the primary manual for the survey, funding/referral references are not required. FUNDING/REFERRAL Reference #1 Title First Name Middle Initial Ms. Barbara Last Name Suffix (Jr., Sr., etc.) Credentials Stuart Work Telephone Extension Address barbara.stuart@azdhs.gov Job Title Program Manager and State Opioid Treatment Authority (SOTA) Organization Name AZ Department of Health Services Mailing Address Address Line 2 Address Line E. Highland Suite 100 City State/Province/Territory Zip/Postal Code Phoenix AZ County/Municipality Maricopa Country US 3 of 13
4 CONTACT INFORMATION SURVEY KEY CONTACT Title First Name Middle Initial Ms. Carmen Last Name Suffix (Jr., Sr., etc.) Credentials Calderon MPA Job Title Executive Director/CEO Address Work Telephone Extension Fax ORGANIZATION INFORMATION Same as Organization to Be Surveyed CONTACT INFORMATION ACCREDITATION LIAISON Same as Survey Key Contact Title First Name Middle Initial Ms. Melody Last Name Suffix (Jr., Sr., etc.) Credentials Chimes Job Title Director, Human Resources and Facilities Address Work Telephone Extension Fax ORGANIZATION INFORMATION Same as Organization to Be Surveyed CONTACT INFORMATION AFTER-HOURS CONTACT Same as Survey Key Contact After-Hours Telephone of 13
5 CONTACT INFORMATION TRAVEL & LODGING CONTACT Same as Survey Key Contact Title First Name Middle Initial Ms. Teri Last Name Suffix (Jr., Sr., etc.) Credentials Lagunas Job Title Administrative Assistant Address Work Telephone Extension Fax ORGANIZATION INFORMATION Same as Organization to Be Surveyed INFORMATION & OUTCOMES MANAGEMENT (IOM) CONTACT CONTACT INFORMATION Same as Survey Key Contact 5 of 13
6 PERSONNEL STATISTICS AND DEMOGRAPHICS Information reported below is for all programs seeking accreditation and should be reported in numbers (not percentages). Total Full-Time Equivalent (FTE) Personnel Actual number of direct-services personnel Employees Contracted Personnel 22 2 Volunteers Total Direct-Services Personnel 0 24 PERSONS SERVED Information reported below is for all programs seeking accreditation and should be reported in numbers served annually (not percentages). Total Number of Persons Served Annually 455 Race/Ethnicity Number of Persons Served Other Race/Ethnicity Description African American/Black 150 Asian 50 White 105 Hispanic/Latino (Ethnicity) 100 Native (American or Alaskan) 5 Gender Number of Persons Served Female 220 Male 225 Age Number of Persons Served Other Age Description (Adult) (Adult) (Adult) 55 If you are using the aging services, CARF-CCAC, medical rehabilitation, or vision rehabilitation services standards manual, you need not complete the following grid. If you are using the business and services management networks standards manual, complete this grid only if you are seeking accreditation for programs/services that you provide directly. Other Characteristics of Persons Served Number of Persons Served Other Description Alcohol and/or Other Addictions 400 Developmental Disabilities 10 Dual Diagnosis AOD/DD 5 Dual Diagnosis AOD/MH 57 Dual Diagnosis MH/DD 2 HIV positive/aids 4 Homeless Individuals 7 Mental Disorders 21 Physical Disabilities 11 Unemployed/Underemployed 39 Visual Impairments 2 Additional information regarding the community, population, or cultures you serve that would be helpful. 6 of 13
7 STANDARDS MANUAL Primary Standards Manual 2014 Opioid Treatment Program INFORMATION FOR SCHEDULING COLLABORATIVE/RELATED SURVEYS CARF/Joint Commission Collaborative Survey Are there any other surveys that should be considered when scheduling this survey? CCAC/EAGLE Collaborative Survey If yes, please describe. CONFLICTS OF INTEREST Have any CARF International surveyors served as consultants to your organization in the last four years? Yes Would surveyors from any specific states/provinces/territories represent a conflict of interest? (DMEPOS surveys, choose N/A option.) If yes, please list names. Don Jorgensen, Ph.D. If yes, please list the states/provinces/territories. Would you accept one team member being assigned to your survey from your own state/province/territory? (DMEPOS surveys, choose N/A option.) Are there any organizations/suppliers considered to be in direct competition with your organization? Are there any geographical areas outside of your state/province/territory from which referrals or significant funding is received? (DMEPOS surveys, choose N/A option.) Are any of your organization's employees current or former CARF International surveyors? Are there any other potential conflicts of interest to avoid? If yes, please list the organizations/suppliers. If yes, please list the geographical areas. If yes, please list names. If yes, please specify. AIRPORT INFORMATION Nearest/Most Convenient Airport Name and City Distance/Time from Hotels Other tes/instructions Tucson International 9 miles/25 minutes OTHER SURVEY LOGISTICS Will the organization provide transportation between locations for the survey team? Provide any additional information that may assist us in arranging your survey logistics. 7 of 13
8 PROGRAMS TO BE SURVEYED PROGRAMS TO BE SURVEYED The grid below identifies the program(s) that are a part of this survey. Program Outpatient Treatment Opioid Treatment Program Adults 8 of 13
9 OPIOID TREATMENT PROGRAM INFORMATION OPIOID TREATMENT PROGRAM STANDARDS MANUAL Outpatient Treatment Opioid Treatment Program Adults Total Number of persons served annually Direct-services personnel in full-time equivalents (FTEs) Does this program provide medication services, including handling, prescribing, dispensing, and/or administration of medications? Yes Does this program use seclusion or restraint? 9 of 13
10 LOCATIONS FOR SURVEY LOCATIONS FOR SURVEY Contact us if changes to locations visited during the survey are necessary. The grid below identifies the location(s) that are required to be visited during this survey. Refer to each location page for details about programs to be surveyed at the location. Location Name Street Address City State/Province/Territory La Frontera, Inc. Hope Center 260 South Scott Street Tucson AZ 10 of 13
11 LOCATION INFORMATION Location Name La Frontera Inc. Hope Center Street Address (no P.O. Box) 260 South Scott Street LOCATION Suite Number, Floor, or Department Does this location operate solely as an administrative site? City State/Province/Territory Zip/Postal Code Tucson AZ County/Municipality Country Telephone Pima US Is this location acting as the survey headquarters? Yes Distance from survey headquarters Miles or kilometres? Direction from survey headquarters Do you want this location's address and Describe any accessibility issues at phone number to be published in our the location. Location Type listings of accredited organizations? ne Owned/leased Yes Days and Hours of Operation Other Other Days/Hours Description M-Th 5am-3:30pm; F5am-12; Sa 7-10am Direct-service personnel in full-time Average number of persons served equivalents (FTEs) at this location for daily at this location for the programs the programs seeking accreditation seeking accreditation STAFF MEMBER RESPONSIBLE FOR OPERATIONS Same as Survey Key Contact PROGRAMS AT THIS LOCATION The grid below identifies the program(s) to be surveyed at this location. Program Outpatient Treatment Opioid Treatment Program Adults OPIOID TREATMENT PROGRAM DETAILS If this site has a mobile unit, where is it Type of OTP Dispensing Location Does this site have a mobile unit? housed? Clinic Program Sponsor First Name Last Name Job Title Sharon McRae-Perez OTP Services Director Work Telephone Extension Address smcrae@lafrontera.org 11 of 13
12 OTP Medical Director First Name Last Name Job Title John Lankton Medical Director Work Telephone Extension Address License Number AZ Identify in the grid below any current program licensure or certification. Licensure/Certification Type License/Certification Number Expiration Date CSAT AZ10111M 11/30/2017 DEA RE /31/ of 13
13 OTHER INFORMATION GROUPS Entities this organization is a member of or affiliated with are listed below. Group AATOD (American Association for the Treatment of Opioid Dependence) APA (Psychiatric) (American Psychiatric Association) APA (Psychological) (American Psychological Association) MHCA (Mental Health Corporations of America) SURVEY ACCESSIBILITY What files or documents do you keep or have available in electronic format? File/Document Policies and Procedures Does CARF International need to provide an interpreter for the survey team to conduct the survey? Description electronic If yes, specify language(s). In what primary language are your organization documents written? English If other, specify language. 13 of 13
Survey Application ORGANIZATION INFORMATION. Organization/Unit Name Acronym Federal Tax Identification Number
Survey Application ORGANIZATION INFORMATION ORGANIZATION TO BE SURVEYED Organization/Unit Name Acronym Federal Tax Identification Number The Arbors Community TAC Organization Website (Example: www.carf.org)
More informationMental Health Association of Southwest Florida
Mental Health Association of Southwest Florida General Information Contact Information Nonprofit Primary Contact First Name Primary Contact Last Name Mental Health Association of Southwest Florida Petra
More informationTHE NEW YORK CITY AIDS FUND
Request for Proposals Date Issued: Thursday, August 23, 2012 Proposal Deadline: Wednesday, October 10, 2012 BACKGROUND Founded in 1989, the New York City AIDS Fund (the AIDS Fund) is a group of grantmaking
More informationIn 2008, an estimated 282,000 persons
National Survey of Substance Abuse Treatment Services The N-SSATS Report January 28, 2010 Similarities and Differences in Opioid Treatment Programs that Provide Methadone Maintenance or Buprenorphine Maintenance
More informationDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES (By authority conferred on the director of the department of licensing and regulatory affairs by
More informationOPIOID USE DISORDER CENTERS OF EXCELLENCE APPLICATION GENERAL INFORMATION
OPIOID USE DISORDER CENTERS OF EXCELLENCE APPLICATION GENERAL INFORMATION The Department of Human Services (DHS) is implementing 50 opioid use disorder (OUD) Health Homes or Centers of Excellence (COE)
More informationEvolutions Recovery House
Evolutions Recovery House General Information Contact Information nprofit Evolutions Recovery House Address 1261 1st Avenue rth Nashville, TN 37210 Phone (615) 593-4387 Fax 615 242-8690 Web Site Web Site
More informationRequest for Proposals for a Clean Syringe Exchange Program
ANNA M. ROTH, RN, MS, MPH HEALTH SERVICES DIRECTOR DAN PEDDYCORD, RN, MPA/HA DIRECTOR OF PUBLIC HEALTH C O N T R A C O S T A P U B L I C H E A L T H 597 CENTER AVENUE, SUITE 200 MARTINEZ, CALIFORNIA 94553
More informationNational Deaf-Blind Equipment Distribution Program Application
Removing communication barriers for people who are Deaf Hard of Hearing Late-Deafened Deaf-Blind Speech Disabled National Deaf-Blind Equipment Distribution Program Application The National Deaf Blind Equipment
More informationCommunity Homelessness Assessment, Local Education and Networking Groups (CHALENG)
June 2016 Community Homelessness Assessment, Local Education and Networking Groups (CHALENG) Community Homelessness Assessment, Local Education and Networking Groups for, commonly referred to as Project
More informationFiscal Year 2019 (July 1, 2018 June 30, 2019) Membership Information & Application
Fiscal Year 2019 (July 1, 2018 June 30, 2019) Membership Information & Application One West Water Street, Suite 260 St. Paul, MN 55107 612.940.8090 www.mnallianceoncrime.org 1 2 About the Minnesota Alliance
More informationState of Louisiana. Louisiana Department of Health Office of Behavioral Health
John Bel Edwards GOVERNOR Rebekah E. Gee MD, MPH SECRETARY State of Louisiana Louisiana Department of Health Office of Behavioral Health Dear Applicant: Congratulations! You have chosen to take the first
More informationBlue Cross and Blue Shield of New Mexico and Lovelace Health Plan Transactions Frequently Asked Questions
Blue Cross and Blue Shield of New Mexico and Lovelace Health Plan Transactions Frequently Asked Questions Blue Cross and Blue Shield of New Mexico (BCBSNM), has received regulatory approval to acquire
More informationZ E N I T H M E D I C A L P R O V I D E R N E T W O R K P O L I C Y Title: Provider Appeal of Network Exclusion Policy
TheZenith's Z E N I T H M E D I C A L P R O V I D E R N E T W O R K P O L I C Y Title: Provider Appeal of Network Exclusion Policy Application: Zenith Insurance Company and Wholly Owned Subsidiaries Policy
More informationAlcohol and chemical dependency Inpatient treatment programs
Alcohol and chemical dependency Inpatient treatment programs Geisinger Marworth Treatment Center P.O. Box 3, Lily Lake Road Waverly, PA 18471-773 800-442-7722 marworth.org 84459-1-8/1-TPRA/DNFLD Geisinger
More informationGENERAL INFORMATION AND INSTRUCTIONS
NON-PARTICIPATING MANUFACTURER CERTIFICATION FOR LISTING ON OREGON DIRECTORY GENERAL INFORMATION AND INSTRUCTIONS Who is required to file this Certification? Any tobacco product manufacturer who is a non-participating
More informationAPPLICATION FOR RECOVERY COACH CREDENTIAL (RC)
APPLICATION FOR RECOVERY COACH CREDENTIAL (RC) International Centre for Credentialing and Education for Addiction Counsellors (ICCE) In collaboration with Provider No. 836 NAADAC, the Association for Addiction
More informationInterior AIDS Association
Interior AIDS Association 710 3 rd Ave Fairbanks, Alaska Phone:452-4222 Website: www.interioraids.org Anna Nelson, Executive Director anna@interioraids.org Brenda Henze-Nelson, M. Ed., CDCS, Clinical Supervisor
More informationCrowe Healthcare Webinar Series
Crowe Healthcare Webinar Series Healthcare Providers Ongoing Challenges With Controlled Substances Presented by: Scott Gerard, Healthcare Risk Consulting Partner Eric Jolly, Healthcare Risk Vice President
More informationNEBRASKA OCA PEER SUPPORT & WELLNESS SPECIALIST TRAINING APPLICATION January 23-27, 2012, Kearney, NE
1 Fax All 7 Pages of Application to: Barb Born 402-471-7859 Or Mail All 7 Pages of Application to: Barb Born Division of Behavioral Health P.O. Box 95026 Lincoln, NE 68509 Email Assistance: Barb.Born@nebraska.gov
More informationPrepublication Requirements
Issued Prepublication Requirements The Joint Commission has approved the following revisions for prepublication. While revised requirements are published in the semiannual updates to the print manuals
More informationAccording to the Encompass Community Services website, the mission of Encompass is
Kymber Senes CHHS 496A 9/17/14 Organizational Analysis 1. Exercise 3.4 a. Briefly describe the mission or purpose of your agency. According to the Encompass Community Services website, the mission of Encompass
More informationFY2018 Michigan Department of Health and Human Services
6/6/18 Page 1 of 1 PIHP Name: Mid-State Health Network Staff: Kim Zimmerman FY018 Michigan Department of Health and Human Services Behavioral Health and Developmental Disabilities Administration Substance
More informationVia Electronic Submission. March 13, 2017
APTQI 20 F Street, NW Suite #700 Washington, DC 20001 Phone: 202-507-6354 www.aptqi.com Via Electronic Submission Centers for Medicare & Medicaid Services Department of Health & Human Services Attention:
More informationI AA P The Indiana Association for Addiction Professionals
I AA P The Indiana Association for Addiction Professionals Indiana Association for Addiction Professionals Certification Application I. Personal Data Name Date Address City/State/Zip Phone (w) / (h) /
More informationTraining Announcement Peer Specialist Certification Training
Georgia Department of Behavioral Health & Developmental Disabilities Judy Fitzgerald, Commissioner Office of the Commissioner 2 Peachtree St., NW, 24-290, Atlanta, Georgia 30303-3142 ~ 404.463.7945 Training
More informationCHAMPS 2013 Region VIII (CO, MT, ND, SD, UT, WY) Summary of Bureau of Primary Health Care (BPHC) Uniform Data System (UDS) Information
CHAMPS 2013 (CO, MT, ND, SD, UT, WY) Summary of Bureau of Primary Health Care (BPHC) Uniform Data System (UDS) Information Table of Contents: September 2014 I. Grantees, Patients, Staffing, Clinic Visits,
More informationJanuary To: All Local CRN CHAPTERS
To: All Local CRN CHAPTERS January 2011 Re: Policies and Procedures for Operation as an Affiliated Local Chapter of the National Kidney Foundation s Council on Renal Nutrition (NKF-CRN) and new Local Chapter
More informationProvider Specialty Profile
This profile was created to capture specific information that will allow us to improve our referral process by closely matching member needs with provider services. Please note that incomplete information
More informationCity of Lawrence 2010 Alcohol Tax Funds Request for Proposals Calendar Year 2010 ( January December) Cover Page
City of Lawrence 2010 Alcohol Tax Funds Request for Proposals Calendar Year 2010 ( January December) Cover Page Agency Name: Program Name: Contact Person: DCCCA, Inc First Step at Lake View Lisa Carter,
More informationImagine Children's Health Center
Imagine Children's Health Center General Information Contact Information Nonprofit Imagine Children's Health Center Primary Contact First Name Molly Primary Contact Last Name Barrow Address 810 Anchor
More informationWIC and WIC BFPC Local Agency Application FY 20XX-20XX
WIC and WIC BFPC Local Agency Application FY 20XX-20XX Please submit all documents electronically to the ITCA WIC Director at mindy.jossefides@itcaonline.com. Required: All documents marked with an asterisk
More informationSAVE THE DATE!!!!
www.mhrecovery.org SAVE THE DATE!!!! CERTIFIED PEER SPECIALIST TRAINING IS COMING TO HARRISBURG, PA!!! FACILITATED BY COPELAND CENTER NATIONAL DIRECTOR FOR WELLNESS & EDUCATION, GINA KAYE CALHOUN NOW ACCEPTING
More informationADONIS AUTISM INC. General Information. Contact Information. At A Glance. Nonprofit ADONIS AUTISM INC. Primary Contact First Name.
ADONIS AUTISM INC General Information Contact Information Nonprofit Primary Contact First Name Primary Contact Last Name ADONIS AUTISM INC Debby Lasek Address 726 98th Av. N. Naples, FL 34108 Phone (239)
More informationAttachment 1 The main and sole purpose of the club is to help members improve their photographic skills. To assist members in achieving that goal we are organized as a social club and the following activities
More informationCertified Peer Specialist Training Application
Please read the CPS Application Supplement before completing application. Go to http://www.viahope.org/resources/peer-specialist-training-application-supplement This training is intended for individuals
More informationBefore the FEDERAL COMMUNICATIONS COMMISSION Washington, DC ) ) ) ) SECOND REPORT AND ORDER AND THIRD FURTHER NOTICE OF PROPOSED RULEMAKING
Before the FEDERAL COMMUNICATIONS COMMISSION Washington, DC 20554 In the Matter of Rates for Interstate Inmate Calling Services WC Docket No. 12-375 SECOND REPORT AND ORDER AND THIRD FURTHER NOTICE OF
More information3726 E. Hampton St., Tucson, AZ Phone (520) Fax (520)
3726 E. Hampton St., Tucson, AZ 85716 Phone (520) 319-1109 Fax (520)319-7013 Exodus Community Services Inc. exists for the sole purpose of providing men and women in recovery from addiction with safe,
More informationLANCASTER COUNTY DRUG AND ALCOHOL COMMISSION
LANCASTER COUNTY DRUG AND ALCOHOL COMMISSION Helping Others Get Help For Alcohol and Other Drug Problems 150 North Queen Street (717) 299-8023 Fax: (717) 293-7252 Rick Kastner Executive Director Rev: January
More informationCARF s Consultative Approach to Long-term Care Accreditation. May 15, 2018
CARF s Consultative Approach to Long-term Care Accreditation May 15, 2018 Presenter Jill Allison, B.Sc., MBA Accreditation Advisor Overview of Workshop About CARF CARF in Canada, MB Value, benefits, outcomes
More informationTraining Announcement Peer Specialist Certification Training
Georgia Department of Behavioral Health & Developmental Disabilities Frank W. Berry, Commissioner Office of the Commissioner 2 Peachtree St., NW, 24-290, Atlanta, Georgia 30303-3142 ~ 404.463.7945 Training
More informationMinnesota s Alcohol and Drug Counselor Workforce,
OFFICE OF RURAL HEALTH AND PRIMARY CARE Minnesota s Alcohol and Drug Counselor Workforce, 2014-2016 HIGHLIGHTS FROM THE 2014 LADC WORKFORCE SURVEY i Overall According to the Board of Behavioral Health
More informationWritten Protocol. Moving Tennessee Forward in Access to Care
Written Protocol Moving Tennessee Forward in Access to Care Skilled Nursing Facilities Nursing Homes Public Health Programs Non- Profit Clinics History of the Legislation for Written Protocol Diana Saylor
More informationTRAINING ANNOUNCEMENT Peer Specialist Certification Training
Georgia Department of Behavioral Health & Developmental Disabilities Frank E. Shelp, M.D., M.P.H., Commissioner Division of Mental Health - Consumer Relations and Recovery Section, Georgia Certified Peer
More informationTaking it to the Next Level: The Potential Benefits of Public/Private Partnerships
Taking it to the Next Level: The Potential Benefits of Public/Private Partnerships Success Through Collaboration Crisis Intervention Response Teams (CIRT) Crisis Consumer Stabilization Initiative (CCSI)
More informationMinnesota. Prescribing and Dispensing Profile. Research current through November 2015.
Prescribing and Dispensing Profile Minnesota Research current through November 2015. This project was supported by Grant No. G1599ONDCP03A, awarded by the Office of National Drug Control Policy. Points
More informationGreetings to all of you who provide valuable and vital health, human and related services in our communities!
WIN 2-1-1..Get Connected. Get answers. November 22, 2016 Greetings to all of you who provide valuable and vital health, human and related services in our communities! We are writing because we need your
More information2013 AUXILIARY AIDS AND SERVICE PLAN FOR PERSONS WITH DISABILITIES AND PERSONS WITH LIMITED ENGLISH PROFICIENCY
Legal Aid Society of Palm Beach County, Inc. Domestic Violence Project 423 Fern Street, Ste. 200 West Palm Beach, FL 33401 (561) 655-8944 ext. 238 Toll-free: (800) 403-9353, ext. 238 Fax: (561) 655-5269
More informationDEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES. Filed with the Secretary of State on
DEPARTMENT OF LICENSING AND REGULATORY AFFAIRS DIRECTOR S OFFICE BOARD OF PHYSICAL THERAPY GENERAL RULES Filed with the Secretary of State on These rules take effect immediately upon filing with the Secretary
More informationREGULATORY IMPACT STATEMENT and COST-BENEFIT ANALYSIS (RISCBA)
State Budget Office Office of Regulatory Reinvention 111 S. Capitol Avenue; 8th Floor, Romney Building Lansing, MI 48933 Phone: (517) 335-8658 FAX: (517) 335-9512 REGULATORY IMPACT STATEMENT and COST-BENEFIT
More informationProvider Specialty Profile
This profile was created to capture specific information that will allow us to improve our referral process by closely matching member needs with provider services. Please note that incomplete information
More informationTraining Announcement Peer Specialist Certification Training
Georgia Department of Behavioral Health & Developmental Disabilities Frank W. Berry, Commissioner Office of the Commissioner 2 Peachtree St., NW, 24-290, Atlanta, Georgia 30303-3142 ~ 404.463.7945 Training
More informationEast End Pregnancy Test & Help Center
East End Pregnancy Test & Help Center General Information Contact Information nprofit East End Pregnancy Test & Help Center Address 4705 Nine Mile Road Richmond, VA 23223 Phone 804 200-9141 Fax 804 564-5852
More informationMinnesota s Dental Therapist Workforce, 2016 HIGHLIGHTS FROM THE 2016 DENTAL THERAPIST SURVEY
Minnesota s Dental Therapist Workforce, 2016 HIGHLIGHTS FROM THE 2016 DENTAL THERAPIST SURVEY Table of Contents Minnesota s Dental Therapist Workforce, 2016... 1 Overall... 3 Demographics... 3 Education...
More informationResidency and Fellowship Training
VA N D E R B I LT P S YC H I AT R Y A N D B E H AV I O R A L S C I E N C E S Residency and Fellowship Training W E L C O M E F R O M T H E C H A I R Psychiatry is changing. The emergence of new knowledge
More informationFACT SHEET. Women in Treatment
FACT SHEET Women in Treatment February 2011 The data in this fact sheet are based on clients in publicly funded and/or monitored alcohol and other drug treatment services in California during State Fiscal
More informationAlbany County Coordinated Entry Assessment version 12, 11/29/16
Referral Completed by: PRE-SCREENING INFORMATION FOR SHELTER REFERRAL 1. First Name Last Name Date/Time: Other names (including nicknames): 2. Has client previously completed an application for assistance
More informationProvider Specialty Profile
This profile w as created to capture specific information that w ill allow us to improve our referral process by closely matching member needs w ith provider services. Please note that incomplete information
More informationSTATE OF NEW JERSEY DEPARTMENT OF CORRECTIONS. Medication Assisted Treatment For Substance Use Disorder In the New Jersey County Jails
STATE OF NEW JERSEY DEPARTMENT OF CORRECTIONS Medication Assisted Treatment For Substance Use Disorder In the New Jersey County Jails NOTICE OF GRANT OPPORTUNITY (Updated) Announcement Date: September
More informationDivision of Behavioral Health Services
Division of Behavioral Health Services Annual Report on Substance Abuse Treatment Programs Fiscal Year 2012 Submitted Pursuant to A.R.S. 36-2023 December 31, 2012 Report Contents Program Names and Locations
More informationImportant: Use the INSTRUCTIONS at the end to fill out each question on this form.
ONE-TIME COMPLIANCE REPORT FOR DENTAL DISCHARGERS To comply with 40 Code of Federal Regulations 441.50 relating to Effluent Limitation Guidelines and Standards for the Dental Office category, this form
More informationOFFICIAL POLICY. Policy Statement
OFFICIAL POLICY 9.1.6 Employee Drug and Alcohol Abuse Policy 2/8/16 Policy Statement Employee Drug and Alcohol Abuse Policy #CofC.HR.DA.03 Revised 12/2001 The Drug-Free Schools and Communities Act The
More informationSelf-Evaluation and Attestation
Legal Provider Name: Agreement No(s): Please submit this completed document with accompanying documentation by: Respond to all statements by placing a checkmark in the applicable box in the Provider Response
More informationArticle XIV: MINIMUM CONTINUING EDUCATION FOR DENTISTS AND DENTAL HYGIENISTS
AMENDMENT MARKUP Article XIV: MINIMUM CONTINUING EDUCATION FOR DENTISTS AND DENTAL HYGIENISTS A. Purpose: The Rules in this chapter set forth the requirements and guidelines for minimum continuing education
More informationCenter for Excellence in Aging and Geriatric Health
Center for Excellence in Aging and Geriatric Health General Information Contact Information Nonprofit Address Center for Excellence in Aging and Geriatric Health 3901 Treyburn Drive Suite 100 Williamsburg,
More informationGLHRN Grant Application
GLHRN Grant Application (One project per application) FUNDING2016 HUD NOFA GRANT PERIOD 2017-18 Application due to coordinator@glhrn.org by 6 pm on Friday, August 12 th PART I: Program Information Renewal
More informationADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans
ADMINISTRATIVE POLICY AND PROCEDURES MedStar Family Choice Medicare Advantage Plans DEPARTMENT: Medicare Compliance POLICY TITLE: RELATED DEPARTMENTS: All POLICY #: 700C VERSION #: 3 REVISION DATE: Medicare
More informationLions Sight & Hearing Foundation Phone: Fax: Hearing Aid: Request for assistance
Lions Sight & Hearing Foundation Phone: 602-954-1723 Fax: 602-954-1768 Hearing Aid: Request for assistance 3427 N 32 nd Street office use only Date received Case number Applicant: (Name; please print clearly)
More information70.4% of clients rated the services they received as excellent and 25.9% rated the services as very good. Specialized Clinical Services:
Our Mission: The Human Services Department seeks to support, strengthen and empower Falmouth residents and the community by ensuring access to a comprehensive range of community-based health and human
More informationSelf-Evaluation for Compliance with Section 504 Accessibility Requirements for Persons with Disabilities
OREGON COMMUNITY DEVELOPMENT BLOCK GRANT PROGRAM Self-Evaluation for Compliance with Section 504 Accessibility Requirements for Persons with Disabilities Note: This self-evaluation must cover all programs
More informationAccreditation is Not a Luxury
Is your organization accredited? Why? Why not? Is it required? What value will be added for your efforts and for your time and energy in seeking accreditation? The Joint Commission, the Council on Accreditation
More information2017 Report Card. 62 acute inpatient rehabilitation beds 13 DAYS
Lovelace UNM Rehabilitation Hospital is dedicated helping each patient overcome the effects of illness and injury through our comprehensive inpatient and outpatient programs. Our highly specialized physicians
More informationARKANSAS STATE BOARD OF ATHLETIC TRAINING 9 SHACKLEFORD PLAZA, SUITE 3 LITTLE ROCK, AR 72211
ARKANSAS STATE BOARD OF ATHLETIC TRAINING 9 SHACKLEFORD PLAZA, SUITE 3 LITTLE ROCK, AR 72211 Application Instructions for Athletic Trainer Licensure/Temporary Permit Education: Athletic trainers seeking
More informationMental Health Interpreter Institute 2006
Mental Health Interpreter Institute 2006 September 12-17, 2006 Montgomery Alabama A Presentation of Mental Health Interpreter Training Project Office of Deaf Services Alabama Department of Mental Health
More information2016 Pharmacist Re-Licensure Survey Instrument
1. Sex a. Male b. Female 2016 Pharmacist Re-Licensure Survey Instrument 2. Ethnicity: Are you Hispanic or Latino? a. Yes b. No 3. Race (Check all that apply.) a. American Indian or Alaska Native b. Black
More informationWellSpan Philanthropy. Third Party Fundraiser Tool Kit
WellSpan Philanthropy Third Party Fundraiser Tool Kit THANK YOU... for your interest in planning an event or program to help raise funds to support WellSpan s mission and benefit the health care needs
More informationCOPA PROGRAM REFERRAL FORM Person must be: Years -Living with Addictions -Living within the Toronto Central LHIN boundaries
COPA PROGRAM REFERRAL FORM Person must be: -55 + Years -Living with Addictions -Living within the Toronto Central LHIN boundaries CLIENT INFORMATION First Name: Last Name: Referral Date: Form completed
More information2014 Report Card. 62 acute inpatient rehabilitation beds days
Lovelace Rehabilitation Hospital is dedicated helping each patient overcome the effects of illness and injury through our comprehensive inpatient and outpatient programs. Our highly specialized physicians
More informationTRAUMA RECOVERY/HAP OPERATING GUIDELINES
TRAUMA RECOVERY/HAP OPERATING GUIDELINES FOR THE NATIONAL TRAUMA RECOVERY NETWORK, THE TRAUMA RECOVERY NETWORK ASSOCIATIONS, AND THE TRAUMA RECOVERY NETWORK CHAPTERS Operating Guidelines These Operating
More information2016 NATIONAL SPONSORSHIP PROGRAM
2016 NATIONAL SPONSORSHIP PROGRAM 2016 NATIONAL CONFERENCE September 12 14, 2016 Phoenix, AZ ARIZONA BILTMORE We are the only association dedicated to corporate foodservice and workplace hospitality, the
More informationLiberty Women's Clinic
Liberty Women's Clinic General Information Contact Information Nonprofit Liberty Women's Clinic Address 1532 NE 96th Street, Suite B Liberty, MO 64068 Phone (816) 415-5111 Website www.strides4life.com
More informationNational Survey of Substance Abuse Treatment Services (N-SSATS)
U.S. Department of Health and Human Services FORM APPROVED: OMB No. 0930-0106 APPROVAL EXPIRES: 01/31/2016 See OMB burden statement on last page National Survey of Substance Abuse Treatment Services (N-SSATS)
More informationS.O.S. Suicide Prevention Program
S.O.S. Suicide Prevention Program 2000-2005 An evidence-based, cost effective program of suicide prevention and mental health screening for secondary schools A Program of Screening for Mental Health, Inc.
More informationPoisonings among Arizona Residents 2014
Poisonings among Arizona Residents 214 Resources for the development of this report were provided through funding to the Arizona Department of Health Services from the Centers for Disease Control and Prevention,
More informationABILITY PEDIATRIC PHYSICAL THERAPY, LLC
ABILITY PEDIATRIC PHYSICAL THERAPY, LLC 4325 Laurel Street, Suite 102 Anchorage, AK 99508-5338 Phone (907) 569-5660 Fax (855) 899-0203 info@abilitypediatric.com PEDIATRIC PT POSITION OPEN Ability Pediatric
More informationOpioid Treatment in North Carolina SEPTEMBER 13, 2016
Opioid Treatment in North Carolina SEPTEMBER 13, 2016 Source Where Pain Relievers Were Obtained for Most Recent Nonmedical Use among Past Year Users Aged 12 or Older: 2007 Source Where Respondent Obtained
More informationMinnesota s Psychology Workforce, 2016
OFFICE OF RURAL HEALTH AND PRIMARY CARE Minnesota s Psychology Workforce, 2016 HIGHLIGHTS FROM THE 2016 PSYCHOLOGY WORKFORCE SURVEY i Overall According to the Minnesota Board of Psychology, as of February
More informationDEPARTMENTS OF MENTAL HEALTH SOCIAL SERVICES AND YOUTH BUREAU
MARYELLEN ODELL County Executive MICHAEL J. PIAZZA, Jr. Commissioner 37A298@dfa.state.ny.us JOSEPH A. DeMARZO Deputy Commissioner Joseph.Demarzo@putnamcountyny.gov GRACE M. BALCER Fiscal Manager 37A279@dfa.state.ny.us
More information(4) Be as detailed as necessary to provide history of work performed; and:
www.omarfigueroa.com Page 66 of 278 (4) Be as detailed as necessary to provide history of work performed; and: (A) Include information adequate to identify any associated manufacturing facility (e.g.,
More informationNEW MEXICO DEPARTMENT OF HEALTH Administrative Manual ADMINISTRATION
Chapter NEW MEXICO DEPARTMENT OF HEALTH Administrative Manual ADMINISTRATION EFFECTIVE: Policy REVISED: 4/13/9 draft NALOXONE DISTRIBUTION POLICY I. PURPOSE: This New Mexico Department of Health (NMDOH)
More informationSIGN LANGUAGE INTERPRETER Job Description
CATEGORY: INSTRUCTIONAL SUPPORT POSITION STATUS: FULL-TIME FLSA STATUS: NON-EXEMPT SALARY CODE: 52 The incumbent in this job is expected to assist the College in achieving its vision and mission of student
More informationPHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL
PHYSICAL MEDICINE AND REHABILITATION CSHCN SERVICES PROGRAM PROVIDER MANUAL NOVEMBER 2017 CSHCN PROVIDER PROCEDURES MANUAL NOVEMBER 2017 PHYSICAL MEDICINE AND REHABILITATION Table of Contents 30.1 Enrollment......................................................................
More informationAccommodation and Compliance Series. Employees with Bipolar Disorder
Accommodation and Compliance Series Employees with Bipolar Disorder Preface The Job Accommodation Network (JAN) is a service of the Office of Disability Employment Policy of the U.S. Department of Labor.
More informationVirginia Medicaid Peer Support Services UM Guideline
Virginia Medicaid Peer Support Services UM Guideline Subject: Virginia Medicaid Peer Support Services Current Effective Date: 08/24/2017 Status: Final Last Review Date: 10/23/2018 Description Peer Supports
More informationJunior Service League of Murfreesboro
Junior Service League of Murfreesboro General Information Contact Information Nonprofit Junior Service League of Murfreesboro Address P.O. Box 4138 Murfreesboro, TN 37129 Phone (615) 848-0901 Fax 615 898-1594
More informationCardboard City Sponsorships 2015
Cardboard City Sponsorships 2015 Become a Cardboard City event sponsor!! On October 17 th the beautiful field of Scottsdale Stadium, home of the world champion San Francisco Giants, will transform into
More informationMarcia Baker
Marcia Baker marbak1@comcast.net Current Work Experience March 2010- present University of Texas Medical Branch Galveston School District after School Coordinator Community Resource Coordinating Group
More informationScientist Survivor Program at the AACR Annual Meeting New Applicant Application
Scientist Survivor Program at the AACR Annual Meeting 2019 - New Applicant Application Applicant Information. Please complete this application in its entirety including the advocate poster section and
More informationVeterans Certified Peer Specialist Training
Please read the CPS Application Supplement before completing application. Go to http://www.viahope.org/resources/peer-specialist-training-application-supplement This training is intended for individuals
More informationDivision of Registrations Gregory Ferland Interim Division Director. Corrected Notice of Proposed Rulemaking and Rulemaking Hearing
Division of Registrations Gregory Ferland Interim Division Director State Physical Therapy Board Deann Conroy Program Director John W. H1ckenlooper Governor Barbara J. Kelley Executive Director Corrected
More information