Follow the steps to effectively complete the form.

1. Press the ‘Get Form’ button to access the document and open it in the editor.
2. Fill in the 'Name of Provider' and 'Address' fields accurately. If the program address differs from the provider's address, provide that information in the designated field.
3. Enter the Director's name, phone number, and email address in the corresponding sections.
4. Indicate your status by checking one of the options: 'New applicant seeking DBHDS license,' 'Licensed provider seeking service modification in the same region,' or 'Licensed provider seeking service modification in a new region.'
5. Specify the type of service provided in the respective field.
6. If applicable, include the name of your Licensing Specialist.
7. In the verification section, the Director must confirm compliance by writing their name and the provider's name, along with completing the necessary compliance statements regarding regulations and policies.
8. Address policies regarding dignity, services, decision-making participation, confidentiality, access to records, and freedom of everyday life as required by the regulations.
9. Decide if the provider will use seclusion, restraint, or timeout, and if so, detail the policy in alignment with the specified regulations.
10. Review and complete any additional policy statements, ensuring understanding of regulations pertaining to complaint resolution, behavioral management, and employee training requirements.
11. The Director must sign and date the form at the end to validate the compliance statements.
12. Once all fields are filled, save the document. You can download, print, or share the completed form as necessary.

Complete your HUMAN RIGHTS COMPLIANCE VERIFICATION FORM online today to ensure proper compliance.