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INSTRUCTIONS

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:

BHSIS Project Office
Eagle Technologies, Inc.
1901 North Moore Street, Suite 702
Arlington, VA 22209
locator@eagletechva.com
FAX: (703) 763-5083
Questions? Call the BHSIS Project Office toll-free at 1-877-250-4665 Monday through Friday, 8 a.m. to 6 p.m. Eastern Time.

FACILITY ELIGIBILITY

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:

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

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



EXPLANATION OF TERMS

Effective Date - Date facility began providing substance abuse 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 abuse and mental health, that are provided at the street address specified on this application form.


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.


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