Section R9-20-203. Application and Renewal

A.      An applicant applying to become a provider shall submit to the Department an application packet that contains:

1.        An application in a format provided by the Department that includes:

a.        The applicant’s name;

b.        The applicant’s mailing address and telephone num- ber;

c.        The applicant’s e-mail address;

d.        The name, telephone number, and e-mail address of the individual acting on behalf of the applicant according to R9-20-202, if applicable;

e.        The name under which the applicant plans to do business, if different from the applicant’s name;

f.         The name of each referring court;

g.        The address and telephone number of the for each facility where treatment is provided; and

h.        The applicant’s signature and the date signed;

2.        A copy of the:

a.        Program description required in R9-20-208(A)(1),

b.        Policies and procedures required in R9-20-208(B), and

c.        Policies and procedures required in R9-20-208(D);

3.        The name and qualifications of the administrator; and

4.        A copy of the applicant’s:

a.        U.S. Passport, current or expired;

b.        Birth certificate;

c.        Naturalization documents; or

d.        Documentation of legal resident alien status.

B.       For renewal, at least 60 days before the expiration of approval, a provider shall submit to the Department in a Department- provided format:

1.        The provider’s approval number,

2.        The information in subsection (A)(1), and

3.        The documentation in subsection (A)(2).

Historical Note

New Section made by exempt rulemaking at 7 A.A.R. 4439, effective October 3, 2001 (Supp. 01-3). Amended by exempt rulemaking at 9 A.A.R. 3214, effective June 30, 2003 (Supp. 03-2). Section repealed; new Section made by exempt rulemaking at 19 A.A.R. 2367, effective October 1, 2013 (Supp. 13-2).