<p> FORM D: APPLICANT READINESS</p><p>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.</p><p>Applicant Organization Name Region</p><p>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</p><p>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. </p><p>4. Provide proof of accreditation by an independent SAMHSA accrediting body. </p><p>5. Provide proof of DEA registration as a qualified NTC. DEA Number: </p><p>6. Attach Applicant’s organization chart, detailing oversight structure (governing body) and staff who will manage clinical services (two-page limit). </p><p>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. </p><p>9. Attach Certificate of Insurance. </p>