Enter the information requested for each item, using the TAB key to move between items. Note that some items MUST be completed. Abbreviations should be avoided. Click the "Submit Form" button toward the bottom of the form when completed.
If you prefer to print the form and submit by fax or mail, send it to:

For the I-BHS, a facility is defined by the street address at which services are provided.
A corporation delivering services at different locations should submit an application for each location.

Mental Health Treatment Facility - The facility must provide mental health treatment services to persons with mental illness.
I-BHS includes:

• Facilities that provide mental health treatment services and are funded by the state mental health agency (SMHA) or another state agency or department.
• Mental health treatment facilities administered by the U.S. Department of Veterans Affairs.
• Private for-profit and non-profit facilities that are licensed by a state agency to provide mental health treatment services, or that are accredited by a national treatment accreditation organization (e.g., The Joint Commission, NCQA, etc.).

Substance Use Treatment Facility - The facility must provide substance use treatment services to persons with substance use or addiction. One of the following must apply:

• The facility has licensure/accreditation/approval to provide substance use treatment from the state substance use agency or a national accrediting body (e.g., The Joint Commission, CARF, NCQA, etc.).
• The facility has staff who hold specialized credentials to provide substance use treatment services.
• The facility has authorization to bill third-party payers for substance use treatment services using an alcohol or drug client diagnosis.

Exclusions - Facilities that are not eligible for I-BHS should not be submitted on this form. These include:

• Facilities that provide either mental health or substance use treatment exclusively to persons who are incarcerated.
• Mental health treatment facilities whose primary or only focus is the provision of services to persons with Mental Retardation (MR), Developmental Disabilities (DD), or Traumatic Brain Injuries (TBI).
• Mental health professionals in private practice (individual) or in a small group practice not licensed or certified as a mental health clinic or (community) mental health center.

Effective Date - Date facility began providing substance use and/or mental health treatment services.

Facility Name - The first line of the facility name should include the corporate name (if applicable) or highest-level name of the facility. When applicable, line 2 of the facility name should include a unit or program name that uniquely identifies the facility.

Services Provided - Check all services, both substance use and mental health, that are provided at the street address specified on this application form.

• Mental Health Treatment - The facility provides interventions such as therapy or psychotropic medication that treat a person’s mental health problem or condition, reduce symptoms, and improve behavioral functioning and outcomes.
• Substance Use Treatment - The facility provides services that focus on initiating and maintaining an individual's recovery from substance use and on averting relapse.
• Detoxification Services - The facility provides services that focus on medical management of acute alcohol or drug intoxication and withdrawal.
• Administrative Services - The facility provides administrative services (such as billing, personnel, and scheduling).
• Other Non-Treatment Services - The facility provides services such as intake, assessment, and referral.

Public Burden Statement: An agency may not conduct or sponsor, and a person is not required to respond to, a collection of information unless it displays a currently valid OMB control number. The OMB control number for this project is 0930-0106. Public reporting burden for this collection of information is estimated to average 5 minutes per respondent, per year including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden, to SAMHSA Reports Clearance Officer, 5600 Fishers Ln, Room 15E57B, Rockville, Maryland 20852.