Form Dhcs 5112 - California Initial Certification Application - Health And Human Services Agency Page 5
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11STATE OF CALIFORNIA--HEALTH AND HUMAN SERVICES AGENCY
Department of Health Care Services
Licensing and Certification Branch, MS 2600
PO Box 997413
Sacramento, CA 95899-7413
INITIAL CERTIFICATION APPLICATION CHECKLIST
CHECKLIST
SECTIONS A & B
Residential and Outpatient programs require separate applications.
This form is to assist in identifying forms and documents needed for initial program certification.
The following pages describe each item in greater detail. All applicants for initial certification
shall submit the following:
SECTION A - INITIAL CERTIFICATION APPLICATION
Initial Certification Application (DHCS 5112). The applicant shall complete all of the information
and documentation contained in this application for certification.
SECTION B - Supportive Documents
Each applicant shall submit to the Department the following documents with the application for
certification.
REQUIRED SUPPORTIVE DOCUMENTS
F
D
U
O
OR
EPARTMENTAL
SE
NLY
PLAN OF OPERATION:
YES
NO
INCOMPLETE
1.
ANNUAL LINE ITEM BUDGET
2.
PROGRAM MISSION AND PHILOSOPHY STATEMENT(S)
3.
PROGRAM DESCRIPTION (Detoxification services require
separate program description)
4.
A STATEMENT OF PROGRAM OBJECTIVES
5.
PROGRAM EVALUATION PLAN
6.
CONTINUOUS QUALITY MANAGEMENT PLAN
7.
AN OUTLINE OF ACTIVITIES AND SERVICES TO BE
PROVIDED BY THE PROGRAM
(Detoxification services require separate outline)
DHCS 5112 (07/13)
Page 5 of 11
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal