Conn. Agencies Regs. § 17-226b-2 - Application for funds

(a) Application for funds under Section 17-226b of the general statutes shall be made on forms provided by the department. The properly completed application forms shall be submitted to the regional director for the region in which the prospective program is located. The application shall be accompanied by (1) a definition of the towns and areas to be served; (2) a plan by means of which the applicant proposes to coordinate its activities with those of other local agencies presently supplying psychiatric or mental health services or contributing in any way to the mental health of the area; (3) a description of the services to be provided, and the methods through which those services will be provided; and (4) indication of the methods that will be employed to effect a balance in the use of state and local resources so as to foster local initiative, responsibility and participation.

(b) The application shall be accompanied by the following information pertaining to the applicant's program (if applicable):

(1) The actual expenses of the program for the previous year;

(2) The latest audited financial statement;

(3) The fee schedule for services;

(4) The latest detailed budget for the applicant organization;

(5) The catchment area council or regional board evaluation report (if already funded by the department);

(6) A list of the Board of Directors of the applicant organization with addresses;

(7) Document showing allocation of federal and other funding;

(8) The name and telephone number for:

(a) Chairman of the Board of Directors;

(b) Administrator of the program;

(c) Program Director; and

(d) Chief Fiscal Officer.

(9) Documentation of approval by:

(a) Health Systems Agency (HSA) and

(b) Commission on Hospitals and Health Care.

(c) Each applicant must have copies of the following on file at the department (if applicable):

(1) All professional licenses;

(2) All facility licenses;

(3) Certificate of incorporation;

(4) Contracts and/or agreements for:

(a) professional consultants;

(b) maintenance;

(c) food service;

(d) third party payments;

(e) town-city;

(f) private individuals; and

(g) lease/rental agreements;

(5) Letters of affiliation of working agreements with other programs/facilities;

(6) Certificates of compliance with:

(a) health codes;

(b) fire and safety codes;

(c) building codes; and

(d) zoning requirements;

(7) Employee surety bonds;

(8) Insurance coverage (cost and extent) for:

(a) casualty;

(b) liability;

(c) mal practice;

(9) Program's organization, policies and procedures;

(10) Program job descriptions.

(d) The applicant shall submit the above information and documents in accordance with the requirements of the application form, as well as any other information the department may reasonably require.

Notes

Conn. Agencies Regs. § 17-226b-2

Effective July 25, 1979