Get License Application

Filling out the LICENSE APPLICATION online is a crucial process for individuals or organizations seeking licensure for substance abuse treatment centers. This guide will provide a clear, step-by-step approach to ensure the application is completed accurately and efficiently.

Follow the steps to successfully complete your application.

1. Click the ‘Get Form’ button to access the application document and open it in your online editor.
2. Begin by filling in the 'Identifying Information' section. Provide the full name and address of your facility, as well as the administrator's name, telephone number, fax number, and preferred email address.
3. Indicate the preferred mailing address if it differs from the facility address provided. Complete this section thoroughly to ensure accurate communication.
4. Input the number of inpatient beds available at your facility. This information is essential for the licensing process.
5. Enter the planned occupancy date for your facility. This helps to set timelines for your operations.
6. Provide the Federal Employer Identification Number of the facility. This is a crucial requirement for the application.
7. In the 'Accreditation/Certification' section, check all applicable boxes to indicate the certifications your facility holds, such as JCAHO or CARF.
8. Specify the special care and treatment types your facility will provide. Tick the relevant options and indicate if you're requesting deemed status.
9. Complete the 'Ownership Information' section by providing the owner's name and mailing address. Include the Social Security Number of the owner if the owner is an individual.
10. Select the type of business organization from the options provided. Attach a list of names and addresses of all persons controlling the facility.
11. Ensure to check whether the organization is a profit or non-profit entity.
12. In the 'Certification' section, read and confirm understanding of the Rules and Regulations. Sign and date as required, indicating your role in the organization as noted.
13. Review all sections carefully for accuracy. Once completed, you can save changes, download, print, or share the form as needed.

Complete your LICENSE APPLICATION online today for a smooth submission experience.