Provider Certification and Licensure

In order to expedite your paperwork or if you have any questions, please email DMHA-CL@fssa.in.gov.

For  compliment, questions or concerns about services, treatments, procedures, rights and/or policies, please refer to the consumer service line flyer linked here.

Addiction Certifications
Addiction Treatment Services Provider (outpatient) - an agency of 10 or fewer direct service staff/volunteers/contract workers

• Required attachments for addiction services providers - outpatient certification
• Application for certification of addiction providers - State form 55376
• Documentation of direct services providers - State form 52810
• Statement of understanding
• Facility facts record - State form 48160
• Article 4.4: Addiction treatment services provider certification

Addiction Treatment Services Provider (regular) - an agency of 11 or more direct service staff (requires accreditation)

• Required attachments for addiction services providers - regular certification
• Application for certification of addiction providers - State form 55376
• Documentation of direct services providers - State form 52810
• Statement of understanding
• Facility facts record - State form 48160
• Article 4.4: Addiction treatment services provider certification

Community Mental Health Centers *Currently not accepting new applicants - all areas of Indiana are designated*

• Required attachments for CMHC renewal
• Application for certification/licensure of CMHC - State form 48161
• Summary sheet of contracted services - State form 53365
• Chart of providers sites and services - State form 53360
• Request for approval to subcontract with for profit - State form 53366
• Direct care staff report - State form 53359
• Facility facts record - State form 48160
• Article 4.1: Community mental health centers certification
• Article 9: Minimum standards for the provision of services by community mental health centers and managed care providers

Opioid Treatment Program *Currently not accepting new applicants - all areas of Indiana are designated*

• Required attachments for OTP renewal
• OTP: Application for certification as an addiction services provider
• Article 10: Minimum standards for the provision of services by opioid treatment facilities and programs

Private Mental Health Institution

• Private Mental Health Institution required attachments
• Application for certification/licensure of Private Mental Health Institution - State Form 52871
• Private Mental Health Institution annual attestation
• Facility facts record - State form 48160
• Article 1.5: Licensure of private mental health institutions

Certifying a Residential Facility

If your organization is not already certified as an Addiction Treatment Services Provider with Regular Certification or Community Mental Health Center, you need to be certified as a Residential Care Provider before applying to be certified as a supervised group living facility or sub-acute stabilization facility.

• Application for certification as a Residential Care Provider - state form 56914
• Interested in opening a sub-acute stabilization facility?
  • Required paperwork for sub-acute stabilization facility certification
• Interested in opening a supervised group living facility?
  • Required paperwork for supervised group living facility certification
• Facility facts record - State form 48160
• Information required for bed waiver request
• Zoning Code Information Affidavit of Application – Marion County Only
• Article 7.5: Residential living facilities for individuals with psychiatric disorders or addictions

Residential Care Provider

• Required attachments for transitional residential facility

Additional Certification Forms

• Indiana Division of Mental Health and Addiction approved addictions counseling credentials
• Indiana Division of Mental Health and Addiction approved accreditation

Additional Rules

• 42 CFR Part 2 -- Confidentiality of Substance Use Disorder Patient Records
• Article 27 Human services
• Article 39 Health records

You may access rules and regulations through the State of Indiana website: http://iga.in.gov/legislative/. Click on "Administrative Code" in the publications column, then click on "Title 440".