ICOTP APPLICATION

We are a group of addiction treatment providers working to effect changes in our industry that will promote ethical, transparent, and effective practices in addiction treatment that will more reliably provide long lasting success.

The attached application is to be used by current and prospective providers that wish to apply to the ICOTP. If you have any questions regarding the accreditation or the application, please contact ICOTP at +1 (800) 514 – 8911.

 APPLICATION INSTRUCTIONS

Please follow these instructions carefully and submit your application only after it has been properly completed and the required supportive documentation has been prepared. Please complete all applicable sections of the application. If a line or question does not apply to you, fill the line or question with “N/A.” If an entire section does not apply to your application, place a check mark in the “N/A” box located in the section heading. You may attach additional documentation if your information does not fit in the appropriate area; however, the spaces for the requested information must be completed. Financial Disclosures: At the time of audit, you will be asked to provide financial records for the past two years, as well as financial projections for the next 12 months. You will also be audited for any marketing expenses, payments and revenue associated therewith. The audit will also review association with labs and costs, expenses and revenue related therewith. The goal of the audit is full transparency. The CEO of your organization should agree to these terms by signing the bottom of the application.

Legal Entity Information

1 Legal Entity Name
2 Program/Facility Name
3 Corporate Address
City
State
Zip Code
4 Mailing Address
City
State
Zip Code
5 Program Website(s) 6 Entity Type The list of entities should be: Corporation LLC Partnership LLP General Partnership Other
7 Type of Organization The list of type of organizations should be: Profit Non-Profit Other
8 Is the applicant credentialed with the Joint Commission or any other organization?
If so, what is the applicant’s membership number?
Please attach the most recent results of reviews performed by agency or organization.
9 Does the applicant have any active licences registered with the state?
If so, please attach copies of the license for each level of care.
10 Individual for Contact (Name & Title) (Preferably CEO, COO, or Clinical Director)
Phone Number
Email Address
11 Facility Information
County
City
State
Zip Code
Phone Number
Site-specific National Provider Identifier (NPI) Number Ownership Information
Owned by applicant Owned by county Leased Other
12 Does the program have multiple locations?
13 Facility Information – 2
County
City
State
Zip Code
Phone Number
Site-specific National Provider Identifier (NPI) Number Ownership Information
Owned by applicant Owned by county Leased Other
14 Facility Information – 3
County
City
State
Zip Code
Phone Number
Site-specific National Provider Identifier (NPI) Number
Ownership Information
Owned by applicant Owned by county Leased Other
15 Facility Information – 4
County
City
State
Zip Code
Phone Number
Site-specific National Provider Identifier (NPI) Number
Ownership Information
Owned by applicant Owned by county Leased Other

Treatment Provider Information

Treatment Provider Information
1 Type of Services Offered (Select all that apply EITHER Residential or Non-Residential)
Residential Detoxification Treatment Planning Group Sessions Individual Sessions Educational Sessions Transitional Planning
Non-Residential
Detoxification
Group Sessions Individual Sessions Educational Sessions Outpatient Treatment Treatment Planning Intensive Outpatient Program (IOP) Case Management Transitional Planning
2 Target Population General Population Men Only Women Only Dual Diagnosis Families Co-Ed/Child (under the age of 18) /Dual Diagnosis Women/Child (under the age of 18) /Dual Diagnosis Women/Children (under the age of 18) Co-Ed/Children (under the age of 18) Elderly Other
3 Hours Of Operation Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
4 Occupancy – How many patients can be held within the facility?
Total Capacity
Ambulatory
Non-ambulatory
Bedridden
Number of Dependent Children (under the age of 18)
5 Are services other than substance use disorder (SUD) treatment services provided at this location?
If so, please list them
6 Please attach a program schedule for clinical services.
7 What is the program’s therapist to client ratio?
Resident (Res)
Partial Hospitalization Program (PHP)
Intensive Outpatient Program (IOP)
8 Does the program/holding company or any principle members (e.g., executives or shareholders with more than 10%) own an interest in a lab? 9 Does the program perform random drug testing for detox and inpatient patients?
If so, what is the program’s protocol? (Please attach a copy) If so, how much does the program bill insurance for the drug tests? Are the drug tests sent out for confirmation? If so, how much does the program bill insurance?
If so, how much does the lab separately bill insurance?
10 Does the program perform random drug testing in IOP and sober living?
If so, what is the program’s protocol? (Please attach a copy)
If so, how much does the program bill insurance for drug tests?
Are the drug tests sent out for confirmation?
If so, how much does the program bill insurance?
If so, how much does the lab separately bill insurance?
11 List each additional lab test done on your patients, including but not limited to: Allergy tests, DNA tests, and so forth.
If so, what is the program’s protocol? (Please attach a copy)
If so, how much does the program bill insurance for drug tests?
Are the drug tests sent out for confirmation?
If so, how much does the program bill insurance?
If so, how much does the lab separately bill insurance?
12 What is the program’s policy on how many times a client can be readmitted into the treatment center?
13 What percentage of patients in the program’s treatment center are readmissions? 14 Total number of staff employed at the facility. Please attach an organizational chart for each location.
Name Number of Staff
Location
Location
Location
Location

Administrative Organization Structure

Administrative Organization Structure
Corportations and LLCs N/A
1 Corporation Name
2 Chief Executive Officer
3 Employer Identification Number (EIN) 4 Incorporation Date
5 Place of Incorporation (City and State)
6 Stockholder Information (Names and addresses of all persons who own 10% or more of Company Stock in the corporation)
7 Governing Board of Directors
Name Title Address Phone Term Expiration
Number of Board Members
Term of Office
Frequency of Meetings
Method of Selection
Partnerships N/A
1 Employer Identification Number (EIN) 2 Type of Partnership
3 Partner Information
Name Type (e.g., General vs. Limited) Phone
Business Address City Zip Code
Sole Proprietorship / Other Associations N/A
1 Organization’s EIN or Sole Proprietor’s SSN
2 Listing of all individuals legally responsible for the Organization
Name Title Telephone Email Address Management Exp.
Administrator, Program Director, Clinic Director Information
1 Name
2 Title
3 Telephone
4 Email Address
5 Address
6 Management Experience
Type Title Date Started Date Ended Reasoning
7 Professional License or Certificate? Yes No
If so, please list.
Type Period Held Issuing Agency
Self-Monitoring
1 What is your program’s selfmonitoring process to evaluate risk?
Marketing Practices
1 Please list all marketing practices utilized by the program (e.g., social media, internet, telephone, mail, staff marketers, call centers, etc.) 2 Does the program market through the use of the Internet?
If so, how many websites does the program have and do they all have the program’s treatment center name on them?
If so, what type of marketing does the program perform on the Internet?
3 Does the program utilize staff marketers?
If so, how are they paid?
How are wages reported? (W2 or 1099)
Are they exclusive to the facility?
Does their compensation depend on their referral volume? If yes, how so?
4 Does the program utilize call centers?
If so, are the call centers in-house or outsourced?
5 Does the facility collect rent for Partially Hospitalization Program (PHP) and Intensive Outpatient Program (IOP)?
6 Does the facility pay for the sober living at another place, in which they do not own?
CEO Affirmation
CEO signature

I am text block. Click edit button to change this text. Lorem ipsum dolor sit amet, consectetur adipiscing elit. Ut elit tellus, luctus nec ullamcorper mattis, pulvinar dapibus leo.