ARKANSAS DEPARTMENT OF HUMAN SERVICES

APPLICATION FOR AN INDEPENDENTLY LICENSED PRACTITONER

To be completed upon initial application to become certified as an Individually Licensed Practitioner

_____ Initial Application _____ Annual Renewal

Name:

Physical Address:
Street Address City State Zip

Mailing Address:
Street Address City State Zip

County: Phone: Fax:

E-mail: Website:

Description of outpatient behavioral health services provided:

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Days of Operation: Business Hours:__________________________

Description of how and by whom clients are covered 24 hours a day/7 days a week, addressing crisis
services as well as routing services delivery:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Do you provide medication management through your facility? ______ Yes ______ No

If not, how is medication management handled for your clients?

_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

Description of How you will collaborate with other agencies/individuals to facility quality and continuity
of care for clients:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

_____________________________________________________________________________________
Signature of Chief Executive Officer (or equivalent) Date

DHS Independently Licensed Practitioner Certification – Form 500

Effective July 1, 2017 Page 1 of 2
Name of Chief Executive Officer (or equivalent) typed or printed

Required Documentation
For Initial Applications Only all of the following information must be attached to the
Independently Licensed Practitioner Certification. Applications not submitted in full will not be
processed.

1. Names, credentials and relevant experiences for backup and medication management
physicians.

2. Names, credentials and relevant experience of applicant’s experience providing behavioral

health services.

3. Copies of any affiliation agreements with other agencies/professionals that provide

behavioral health services for your clients.

4. Copies of pertinent certifications and/or licenses (i.e. JCAHO, CARF, staff licensure or
certification by State boards to practice behavioral health services, etc.). Applicant MUST
submit Arkansas licensure which grants the applicant that authority to engage in
private/independent practice by the appropriate State Board.

5. Copies of any forms used for documentation (treatment plan, psychosocial history, etc.)

6. Copies of all correspondence and e-mails (e-mails may be copied to the DHS) between the
agency and the accrediting organization that pertains to the accreditation of the provider’s
outpatient behavioral health services.

DHS WILL REVIEW THIS APPLICATION WITHIN NINETY (90) CALENDAR DAYS OF
RECEIPT.

DHS WILL SCHEDULE AN ONSITE SURVEY WITHIN FORTY-FIVE (45) CALENDAR

DAYS OF APPROVING ALL REQUIRED INITIAL CERTIFICATION
DOCUMENTATION.

Please send a cover letter and all application materials to be certified by DHS as an
Independently Licensed Practitioner to the following address:

Department of Human Services

Licensure and Certification Unit
ATTN: Kayla Pride
PO Box 8059, Slot 408
Little Rock, AR 72203
Kayla.Pride@dhs.arkansas.gov
501-320-6025
DHS Independently Licensed Practitioner Certification – Form 500
Effective July 1, 2017 Page 2 of 2