Rate Certification Form Outpatient - Delaware Department Of Services For Children, Youth And Their Families Page 4

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State of Delaware
Division of Management Support Services
The Department of Services
Cost Recovery Unit
For Children, Youth and
Their Families
ACCREDITATION STATUS FORM
This agency is not accredited.
This agency is accredited. Documents confirming accreditation such as certificates are attached.
Agency Name
Accrediting Organization(s),
i.e. JCAHO, CARF, COA, etc.
Period of Accreditation START Date
Period of Accreditation END Date
Please detail which parts of your organization are covered by the accreditation standards. If your entire organization is accredited, it
is only necessary to indicate “All” instead of providing a comprehensive list. In addition please specify facility or campus names, if
applicable, included in the survey within each service area.
Signature of Person Completing Form
Printed Name of Person Completing Form
Date
Phone Number
Email address
Please provide copies of accreditation certificate(s).
Outpatient
Revised 12/2013
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