Form I-BHS Facility app I-BHS Facility app I-BHS Facility application

Attachment A2 - I-BHS Facility application form
OMB No. xxxx-xxxx
Expiration date: xx/xx/xxxx
See OMB burden statement on last page.

SAMHSA

INVENTORY OF BEHAVIORAL HEALTH SERVICES (I-BHS)
FACILITY APPLICATION FORM

Please complete this application form to request that your facility be added to SAMHSA's Inventory of
Behavioral Health Services (I-BHS). See Instructions on next page.

1. EFFECTIVE DATE:

Jan

1

2013

2. FACILITY INFORMATION
Facility Name (1):
Facility Name (2):
Street Address (1):
Street Address (2):
City:

State:

Zip Code:

County:

Mailing Address (1):

Check if same as Street Address

Mailing Address (2):
City:

State:

Telephone/Extension: ###

###

####

Director's Name:

x####

Zip Code:

Fax:
Director's E-Mail:

Website Address (URL):
3. SERVICES PROVIDED (check all that apply):
Substance Abuse Services

Mental Health Services

Treatment

Treatment

Detoxification

Administrative Services

Administrative Services

Other Non-Treatment Services

Other Non-Treatment Services

INSTRUCTIONS
Type the information requested for each item, using the TAB key to move between items. Note that some
items MUST be completed. Abbreviations should be avoided. Click “Submit Form” in the upper right corner when completed. If you prefer to print this page and submit by fax or mail, send it to:
I-BHS Project Office
Synectics for Management Decisions, Inc.
1901 North Moore St., Suite 900
Arlington, Va. 22209
[email protected]
FAX: (703) 528-8990

Questions? Call the I-BHS Project Office toll-free at 1-888-301-1143
Monday through Friday, 9 am to 5 pm Eastern Time

FACILITY ELIGIBILITY
For the I-BHS, a facility is defined by the street address at which services are provided. A corporation de-

livering services at different locations should submit an application for each location.

Mental Health Treatment Facility - The facility must provide mental health treatment services to persons
with mental illness. I-BHS includes:
Public mental health facilities that are funded by the State mental health agency (SMHA) or other
State agency or department.
Mental health treatment facilities administered by the Department of Veterans Affairs.
Private for-profit and non-profit mental health facilities that are licensed by the State or accredited by
a national accreditation organization.
Substance Abuse Treatment Facility - The facility must provide substance treatment services to persons with substance abuse or addiction. One of the following must apply:
The facility has licensure/accreditation/approval to provide substance abuse treatment from the State
substance abuse agency or a national accrediting body (e.g., JCAHO, CARF, NCQA, etc.).
The facility has staff who hold specialized credentials to provide substance abuse treatment services.
The facility has authorization to bill third-party payers for substance abuse treatment services using
an alcohol or drug client diagnosis.
Exclusions - Facilities that are not eligible for I-BHS should not be submitted on this form. These include:
Facilities that provide either mental health or substance abuse treatment exclusively to persons who
are incarcerated.
Mental health treatment facilities whose primary or only focus is the provision of services to persons
with Mental Retardation (MR), Developmental Disability (DD), and Traumatic Brain Injuries (TBI).
Mental health professionals in private practice (individual) or in a small group practice not licensed or
certified as a mental health clinic or (community) mental health center.

EXPLANATION OF TERMS
Effective Date - Date facility began providing substance abuse and/or mental health treatment services
Facility Name - The first line of the facility name should include the corporate name (if applicable) or
highest-level name of the facility. When applicable, line 2 of the address should include a unit or program
name that uniquely identifies the facility.
Services Provided - Check all services, both substance abuse and mental health, that are provided at
the street address specified on this application form.
Mental Health Treatment - The facility provides services that focus on initiating and maintaining an individual's recovery from, or ongoing treatment of, a mental illness.
Substance Abuse Treatment - The facility provides services that focus on initiating and maintaining
an individual's recovery from substance abuse and on averting relapse.
Detoxification Services - The facility provides services that focus on medical management of acute
alcohol or drug intoxication and withdrawal.
Administrative Services - The facility provides administrative services (such as billing, personnel, and
scheduling).
Other Non-Treatment Services - The facility provides services such as intake, assessment, and referral.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to
respond to, a collection of information unless it displays a currently valid OMB control number. The
OMB control number for this project is xxxx-xxxx. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or
any other aspect of this collection of information, including suggestions for reducing this burden, to
SAMHSA Reports Clearance Officer, 1 Choke Cherry Road, Room 2-1057, Rockville, Maryland
20857.