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 or Facility Name:
3.
Corporate Address:
4.
Mailing Address:
5.
Program Website Address:
6.
Entity Type:
CorporationLLCPartnershipLLPGeneral PartnershipOther
7.
Type of Organization:
ProfitNon-ProfitOther
8.
Is the applicant credentialed with the Joint Commission or any other organization?
YesNo
8.b
Please attach the most recent results of reviews performed by above agency or organization.


9.
Does the applicant have any active licences registered with the state?
YesNo
9.b
If you answered yes to question 9 above, please attach copies of the license for each level of care.


10.
Person to Contact (Preferably CEO, COO, or Clinical Director)
11.
Facility Information
11.b
Facility Ownership Information
Owned by ApplicantOwned by CountyLeasedOther
12.
Does the program have multiple locations?
YesNo
13.
Facility #2 Information
13.b
Facility #2 Ownership Information
Owned by ApplicantOwned by CountyLeasedOther
14.
Facility #3 Information
14.b
Facility #3 Ownership Information
Owned by ApplicantOwned by CountyLeasedOther
15.
Facility #4 Information
15.b
Facility #4 Ownership Information
Owned by ApplicantOwned by CountyLeasedOther

Treatment Provider Information

1.
Type of Services Offered
(Select all that apply EITHER Residential or Non-Residential)
Residential
DetoxificationTreatment PlanningGroup SessionsIndividual SessionsEducational SessionsTransitional Planning
Non-Residential
DetoxificationGroup SessionsIndividual SessionsEducational SessionsOutpatient TreatmentTreatment PlanningIntensive Outpatient Program (IOP)Case ManagementTransitional Planning
2.
Target Population
General PopulationMen OnlyWomen OnlyDual DiagnosisFamilies Co-Ed/Child (under the age of 18) Dual DiagnosisWomen/Child (under the age of 18) Dual DiagnosisWomen/Children (under the age of 18)Co-Ed/Children (under the age of 18)ElderlySpecialty Program (i.e., program designed for First Responders, Lawyers, etc.)Other
3.
Hours Of Operation
4.
Occupancy - How many patients can be held within the facility?
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?
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?
YesNo
9.
Does the program perform random drug testing for detox and inpatient patients?
YesNo
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? YesNo
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?
YesNo
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? YesNo
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.
YesNo
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? YesNo
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.

Administrative Organization Structure - Corporations and LLCs

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




7a.
Number of Board Members
7b.
Term of Office
7c.
Frequency of Meetings
7d.
Method of Selection

Partnerships

1.
Employer Identification Number (EIN)
2.
Type of Partnership
7.
Partner Information


Name




Type Partner




Phone




Street Address




City, Zip Code




Sole Proprietorship / Other Associations

1.
Organization's EIN or Sole Proprietor's SSN
2.
Listing of all individuals legally responsible for the Organization


Name




Title




Phone




Email Address




Management Exp.




Administrator, Program Director, Clinic Director Information

1.
Administrator / Director Info


Name
Title
Phone
Email Address
Management Exp.
2.
Management Experience


Name



Title



Phone



Email Address



Reasoning



3.
Professional License or Certificate?
YesNo


If so, please list.
Type



Period Held



Issuing Agency



Self-Monitoring

1.
What is your program's self monitoring 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?
YesNo

If so, how many websites does the program have and do they all have the program's treatment center name on them?

3.
Does the program utilize staff marketers?
YesNo

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?
YesNo

If so, are the call centers in-house or outsourced?

In-HouseOutsourced

5.
Does the facility collect rent for Partially Hospitalization Program (PHP) and Intensive Outpatient Program (IOP)?
YesNo
6.
Does the facility pay for the sober living at another place, in which they do not own?
YesNo
7.
What referral sources are used by the organization?

CEO Affirmation

CEO Signature
(Use your mouse or touchpad to write your signature in the box below)