Certification Forms

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Adjunctive Medications Forms

These medications must be prescribed by a physician in conjunction with state certified chemical dependency treatment and require a completed authorization form for Medicaid payment. 

• Buprenorphine/Suboxone Authorization Form (DSHS 13-720)
• Campral Authorization Form (DSHS 13-749)
• ReVia Authorization Form (DSHS 13-677)
• Buprenorphine/Suboxone Exemption Request Form (DSHS 13-750)
• Vivitrol IM Physician Prior Authorization Form (DSHS 13-791) [PDF] or [Word]
  
  Shortcut to Adjunctive Medications web page (info re opiate treatment and alcoholism)

Opiate Treatment Application Forms

These forms are used in addition to the application process for DASA Certification and/or Accreditation as an Opiate Treatment Program Provider (OTP) in Washington State.

• OTP Application Addendum [PDF] or [Word] (fill-in form)  new!!  
   
• Community Relations Plan [PDF] or [Word] (fill-in form)  new!!  
   
• Community Relations Plan Attachment List [PDF] or [Word]  new!!  
   
• DASA Certification Procedure No. CS-21, OTP Certification/Accreditation Applications [PDF] or [Word]  new!!  
• Important Web Links for OTP Applicants [PDF] or [Word]  new!!  

Public Disclosure Request Forms:

• Request for Records, DSHS 17-041 (To request DASA records, including records about a DASA contracted or certified agency.)
• Authorization DSHS 17-063 Request for Patient Records (Purpose: Use this form to request the release of your confidential patient/client information held by DSHS to another party.) 

New Applicants for Chemical Dependency Service Certification Forms:

• New Service Provider Certification
  Application Form [Word] (fill-in form) or [PDF]
  Instructions and FAQs [Word] (fill-in form) or [PDF]
  Sample Floor Plan
  ADA Checklist for Existing Facilities
   
• Criminal Background Check form (from Washington State Patrol) [PDF Fill-In]  
  Must use the Request for Child/Adult Abuse Info Act form. To access the form in Word or PDF, click on "FORMS" on the WSP WATCH website https://watch.wsp.wa.gov/Help?Index=forms

Currently Certified Chemical Dependency Service Provider Application-type Forms:

• Certified Provider Branch Agency Certification
  Branch Application Form
  Instructions
  Sample Floor Plan
  ADA Checklist for Existing Facilities
   
• Certified Provider Added Service Certification
  Added Services Application form
  Instructions
  Sample Floor Plan
  ADA Checklist for Existing Facilities
   
• Change of Ownership Application (CHOW)
  CHOW Application Form
  CHOW Instructions
   
• Administrator Change Notification Form
   
• Criminal Background Check form (from Washington State Patrol) [PDF Fill-In]  
  Must use the Request for Child/Adult Abuse Info Act form. To access the form in Word or PDF, click on "FORMS" on the WSP WATCH website https://watch.wsp.wa.gov/Help?Index=forms
   
• Voluntary Certification Suspension/Cancellation Request Form for an agency, branch, or service

• Agency Relocation Approval Request Form and
  Sample Floor Plan

Annual Re-certification and Fees:

• Fee Declaration Form [PDF] or [Word]
  (Purpose: Certified agencies complete this form yearly when they pay their annual certification fee.  The new certificate of approval is mailed once DASA receives the fee, if any, with the Fee Declaration Form.  Agencies with a zero-due reduced or exempt fee still need to fill out the form and send it back to DASA Certification Section.  Your new certificate will be sent once DASA receives the Certification Fee Declaration Form.)
   
• Fee Waiver Request Form
  [Word] (fill-in form) or [PDF] (for printing)
  (Purpose: Certified agencies can complete this to have a reduction or waiver of their annual certification fee considered.)
   
• WAC 388-805 text re Agency Certification Fees [Word]

OTHER INFORMATIONAL DOCUMENTS AND FORMS:

• ASAM PPC-2R Manual Order Form
   
• Consultants -- List of Private Consultants: 
  Policy and Procedure Development [PDF] or [Word]
  Outcomes Development [PDF] or [Word]
   
• Release of Confidential Information Use this form to request a certified treatment agency to send your records to another party.  This is a Sample fill-in form (HIPAA & 42 CFR Part 2 compliant).  Do not use this form for records held by DSHS.  The requirement that the patient's revocation be in writing was removed from this form per the recommendation of the Legal Action Center www.lac.org.    updated!!
   
• Patient Record Disposition -- Disposition of patient records accumulated during your agency's period of certification
   
• Multi-Party DOC CJS Release of Confidential Information (Criminal Justice System / Multi-party Authorization for Release of Information, Department of Corrections (DOC) Form #14-029)
  This form can be used between DOC, a Mental Health treatment provider, an Alcohol or Drug Treatment Provider, and/or the County-Designated Chemical Dependency Professional.
   

• DOL's "Assessment/Treatment Report for DASA Certified Agencies" (formerly called the "blue form")
   

• (ADA) Checklist for Existing Facilities American with Disabilities Act (needed for agency applications & relocations)
   
• Sample Floor Plan [Word] (fill-in form) [PDF] (for printing)
   
• Criminal Background Check form (from Washington State Patrol) [PDF Fill-In]  
  Must use the Request for Child/Adult Abuse Info Act form. To access the form in Word or PDF, click on "FORMS" on the WSP WATCH website https://watch.wsp.wa.gov/Help?Index=forms
   
• Off-site Certified Chemical Dependency Service Information
   
• Consumer Complaint Form (Use this form to submit a complaint to DASA about a certified agency) [Word] (fill-in form) or [PDF] (for printing)
   
• Writing Policies, Procedures, and the Program Manual (a discussion paper) [PDF] or [Word]  
   
• Chemical Dependency Professional Trainee (CDP Trainee) SAMPLE forms
   
  • SAMPLE Approved Supervisor -- Documentation of Qualifications for CDP Trainee [PDF] or [Word]  
  • SAMPLE CDP Trainee Training Plan Documentation form [PDF] or [Word]
  • Counseling Staff Worksheet (includes total face-to-face patient hours for each of the last three months and number of patients assigned to each counselor) [PDF] or [Word]  

• Sample Patient Placement-Type Forms:

• SAMPLE Adult Assessment
• SAMPLE Youth Assessment
• Outpatient Progress Notes
• Intensive Outpatient Progress Notes
• Treatment Plan Review -- Continued Service Preview (CSR)
• Individualized Treatment Plan
• Discharge Transfer Summary
   

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Links to:

DSHS Forms Web Site: http://www1.dshs.wa.gov/msa/forms/index.html

TARGET Forms  http://www1.dshs.wa.gov/DASA/services/target/T2KeForms.shtml

Certification Main page (including WACS, WIG, RCWs, CFRs)

Certification FAQs about Agency Certification & Applications

Greenbook -- "Directory of Certified Chemical Dependency Services in Washington State"

The Publicly-Funded Residential Treatment Provider's Directory [PDF]

SAMHSA/CSAT Facility Locator http://dasis3.samhsa.gov/ (National Directory)

Chemical Dependency Professional (CDP) program at Department of Health (DOH), Professional Licensing

Registered Counselor Program at DOH

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