Provider Certification and Licensure

Addiction Certifications
Addiction Treatment Services Provider (Outpatient) - an agency of ten or fewer direct service staff/volunteers/contract workers

• Required attachments for addiction services providers - outpatient certification
• Application for certification of addiction providers - State form 55376
• Documentation of direct services providers - State form 52810
• Article 4.4: Addiction treatment services provider certification
• Statement of understanding

Addiction Treatment Services Provider (Regular) - an agency of eleven or more direct service staff (requires accreditation)

• Required attachments for addiction services providers - regular certification
• Application for certification of addiction providers - State form 55376
• Article 4.4: Addiction treatment services provider certification

Community Mental Health Centers

• Required attachments for CMHC renewal
• Application for certification/licensure of CMHC - State form 48161
• Summary sheet of contracted services - State form 53365
• Chart of providers sites and services - State form 53360
• Request for approval to subcontract with for profit - State form 53366
• Direct care staff report - State form 53359
• Facility facts record - State form 48160
• Article 4.1: Community mental health centers certification
• Article 9: Minimum standards for the provision of services by community mental health centers and managed care providers

Opioid Treatment Program

• Required attachments for OTP renewal
• OTP: Application for certification as an addiction services provider
• Article 10: Minimum standards for the provision of services by opioid treatment facilities and programs

Private Mental Health Institute

• Private Mental Health Institute required attachments
• Application for certification/licensure of Private Mental Health Institute - State Form 52871
• Private Mental Health Institute annual attestation
• Facility facts record - State form 48160
• Article 1.5: Licensure of private mental health institutions

Residential Care Provider

• Required attachments for residential care provider
• Required attachments for supervised group living facility or sub-acute stabilization facility
• Required attachments for transitional residential facility
• Facility facts record - State form 48160
• Article 7.5: Residential living facilities for individuals with psychiatric disorders or addictions

Additional Certification Forms

• Indiana Division of Mental Health and Addiction approved addictions counseling credentials
• Indiana Division of Mental Health and Addiction approved accreditation

Additional Rules

• 42 CFR part 2
• Article 27 Human services
• Article 39 Health records

You may access rules and regulations through the State of Indiana website: http://www.in.gov/legislative/. Click on "Administrative Code" in the publications column, then click on "Title 440".