Integrated Co-Occurring Disorders Provider Organization Application

Organization or Program Name*

Physical Address of the Organization*

Fill in the complete addressing including city, state and zip code

County of the Organization*

Select the county

Select or enter value

Provider Type*

Select one or both

Mental Health-33

SUD-03

Organization Medicaid Number*

Primary Medicaid number for billing

Organization Secondary Medicaid Number

This could be your Mental Health number or your SUD number (if you have 2 numbers)

Organization NPI Number

Organization Contact name*

Organization Contact Email Address*

Organization Tax ID Number*

Level of Service

Select one or both services.

Residential

Outpatient

Opt in for TA*

Check the box below if you are interested in learning more about free program development technical assistance for programs. An ICD staff member will reach out to you

Select or enter value

Attestation Staff Changes

Please check to indicate understanding that your organization agrees to update OHA ICD on staff changes on a quarterly basis (OHA ICD will provide reporting form and reminders)

I understand*

Attestation Staff Training

Please check to indicate understanding that your organization will support ICD treatment staff in your agency to complete required ICD trainings within one year per OAR 309-019-0145

I understand*

Indicate that you and your organization understand that your ICD program must employ or contract – and actively recruit vacancies – for staff credentialed to provide services in the following scopes of practice

QMHP or licensed Mental Health Provider

CADC or otherwise credentialed or registered Substance Use Disorder Provider

CGAC (Certified Gambling Addiction Counselor), registered candidate, or SUD/MH provider designated by program to provide Integrated Co-Occurring Disorders Problem Gambling treatment as the Integrated Co-Occurring Disorders Problem Gambling Specialist (and complete relevant trainings per OAR 309-019-0145)

LMP (Licensed Medical Provider) that can provide direct care psychiatric medication evaluation and services to individuals enrolled in the program

Peer Services Provider credentialed as Peer Support Specialist, Peer Wellness Specialist or Certified Recovery Mentor

I understand that approved Integrated Co-Occurring Disorders treatment provider organizations are required to have practitioners on staff that practice and will provide services within all five scopes of practice described above*

Please upload the following documents:*

1) Certifications of Approval for your organization as a Behavioral Health provider

2) Policies and Procedures that include your Integrated Co-occurring Disorders Policies and Procedures

3) ICD provider Form (form is available for download at www.oregon.gov/icd)

Drag and drop files here or

Privacy Statement

Information submitted to OHA by applicants for ICD program approval will be considered and will be a public record under Oregon’s Public Records Law. However, that does not necessarily mean that all of the information you submit would be subject to disclosure if OHA received a public records request. Some of the information you submit can be protected from disclosure because it falls within the personal privacy exemption under the Public Records Law. OHA is committed to complying with Oregon’s Public Records Law, but is also committed to protecting the personal privacy of individuals that are required to submit information to OHA, to the extent permitted by law. In addition, OHA could be required to disclose information you submit if legally required to do so by a subpoena or court order.

1. The information provided on the application is valid and complete;

2. The agency will comply with the Oregon Administrative Rules that govern these services;

3. If applicable, the agency is compliant with all other licensing or accreditation entities that apply, i.e., Department of Human Services, Drug Enforcement Administration (DEA), etc.

Check the box attesting

I understand that the information I submit to Oregon Health Authority is considered public record

Date Submitted

Send me a copy of my responses