REQUEST FOR APPLICATION
The Oklahoma Department of
Mental Health and Substance Abuse Services (DMHSAS) requests applications from
traditional, faith and community-based and other non-traditional providers of
services to persons with substance use disorders. Services described in response to this
Request for Application (RFA) shall support consumers’ recovery from substance
use disorders. Services described shall
be recognized as Assessment, Treatment, and Recovery Support Services and
provide services to eligible consumers in accordance with the federal Access to
Recovery (ATR) program as described through the Oklahoma Access to Recovery
(OATR) Program and detailed in the OATR
Participating Provider’s Handbook..
To be considered for designation as a provider of Assessment, Treatment, and/or Recovery Support Services in the OATR program, a provider must submit an application in compliance with the requirements described in this Request for Application and meet the eligibility requirements described in this request.
APPLICATION INSTRUCTIONS
1.
Applicant Signature. Responses must contain original
signatures on all forms requiring signatures. Signatures must be from an official appointed by the organization’s governing body
with the authority to bind the organization.
2.
Application Preparation and Assembly. Complete and return all required forms to the
address indicated below. A complete application consists of responses to all
information listed in this document.
3.
Applications must be sent to the following address:
Attention: Janice Reese
DMHSAS
4.
Please do not submit application by facsimile (FAX) or electronic mail
transmission (email).
5.Upon receipt, the
application will be screened by OATR personnel. When all criteria have been met,
a Cooperative Agreement will be offered.
Complete the items listed below in Sections I &
II:
1. a-j. Enter the legal name of
the applicant organization and the business (DBA) name if appropriate. Enter
the name of the person completing the application. Complete the address, county
where the headquarters is located; fax number of the organization and the email
address where official business correspondence can be directed. Enter the names
and telephone numbers for the executive director, program director(s),
financial contact and board chair.
2. Enter Employer
Identification Number of applicant as assigned by the Internal Revenue Service.
3. Check the
applicant type that best describes applicant organization. If “other,” specify
type of organization. Please check “faith-based” if you choose to identify your agency as such.
4. If an answer of yes is
given for 4a, 4b, 4c, 4d, or 4e, please provide or attach an
explanation.
5. Review application certification
statement.
6. Enter name of Executive
Director and original signature and date.
7. Enter name of
Authorized Certifying Official (Board President, etc.), title, original signature,
and date.
APPLICATION
Download a PDF copy of the Application by clicking
here.