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 number; c. The applicant’s email address; d. The name, telephone number, and email 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 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).