Get Division Of Behavioral Health And Recoverydshs

Filling out the Division Of Behavioral Health And RecoveryDSHS form is a straightforward process that ensures your request for certification suspension or cancellation is properly submitted. This guide provides a detailed step-by-step approach to help users navigate the form with ease.

Follow the steps to successfully complete your request.

1. Click 'Get Form' button to access the form you need, making it available for your use and editing.
2. Begin by entering the name of your agency as it appears on your most recent Certificate of Approval in the designated field.
3. Provide the agency number relevant to this request, ensuring it matches the number on your Certificate of Approval.
4. Select whether you are requesting a voluntary certification suspension or cancellation by checking the appropriate box.
5. In the space provided, briefly describe the reason for your request, ensuring to keep the explanation clear and concise.
6. Indicate what you are requesting suspension or cancellation for by selecting from options such as entire agency, specific branch, or specific services.
7. If applicable, specify the treatment services for which the suspension or cancellation is requested by checking all relevant boxes.
8. Enter the effective date of suspension or cancellation of certification in the MM/DD/YY format.
9. For branches or the entire agency, provide the patient record custodians' name, mailing address, and contact information.
10. Ensure that all declarations at the end of the form are accurately completed, including your signature, date, address, phone number, and title.
11. Once everything is filled out, review your entries for accuracy before saving your changes, downloading, printing, or sharing the completed form as needed.

Complete your voluntary certification suspension or cancellation request online today.