Universal Service - Rural Health Care Program

Approval by OMB 3060-0804

Estimated time per response: 0.5 hours

Rural Health Care Universal Service

Community Mental Health Center Checklist

To verify the eligibility of this Community Mental Health Center to participate in the Rural Health Care Support Mechanism, complete the following information and provide a copy of the health care provider’s (HCP) operating license and the operating license/certification number. This form and the HCP’s operating license (and the operating license/certification number) must be submitted with the FCC Form 460 or 465.

To the extent the Community Mental Health Center includes a long-term care facility, such as a residential substance abuse treatment center, that portion would not be eligible for support.

Complete the information below and check the services provided at the physical location of the HCP:

HCP NUMBER (if known):

HCP NAME:

HCP PHYSICAL ADDRESS:

State License/Certification (if available): For the above physical location, provide a copy of the state license/certification and provide the license/certification number:

Services Provided at the Physical Location (check all that apply):

The facility offers outpatient mental health treatment.

The facility offers 24-hour emergency care for mental health patients.

The facility provides day hospital treatment for mental health patients.

The facility provides other partial hospitalization services for mental health patients.

The facility provides psychosocial rehabilitation services.

The facility provides pre-admission screening for patients being considered for admission to state mental health facilities.

The facility provides residential treatment.

Signature: Date:

Name: Title:

Email: Phone: