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 - (ASO) 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 - (ASR) regular certification
• Application for certification of addiction providers - State form 55376
• Article 4.4: Addiction treatment services provider certification

Community Mental Health Centers (CMHC)

• 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 (OTP)

• 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 (PIP)

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

Residential Care Provider (RCP)

• Required attachments for residential care provider
• Required attachments for supervised group living facility (SGL) or sub-acute stabilization facility (SUB)
• Required attachments for transitional residential facility (TRS)
• 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".