Form D: Applicant Readiness

FORM D: APPLICANT READINESS

This section details the applicant’s readiness as it relates to project described in this OE. NOTE: Applicant must submit a separate and complete enrollment application and required documents for each clinic site.

Applicant Organization Name Region

1.i.1. Clinic Site / License Information License Number Clinic’s Physical Address, City, & Zip Code County State the number of slots that will be committed to HHSC for Committed Capacity

2. Attach documentation of current facility licensure as a Narcotic Treatment Clinic (NTC). Date DSHS facility licensure was issued for NTC. NOTE: DSHS facility licensure must be held directly by your organization. 3. Provide proof of SAMHSA certification. Attach documentation of SAMHSA certification.

4. Provide proof of accreditation by an independent SAMHSA accrediting body.

5. Provide proof of DEA registration as a qualified NTC. DEA Number:

6. Attach Applicant’s organization chart, detailing oversight structure (governing body) and staff who will manage clinical services (two-page limit).

7. Provide copy of Texas Medicaid and Healthcare Partnership (TMHP) that lists enrollment date, effective date, and Texas Provider Identifier (TPI) number. 8. Provide organization’s Medicaid provider (NPI) number.

9. Attach Certificate of Insurance.