Membership Update

System Membership Application

Step 1 of 4 - Contact Information

10%

Contact Information

System Information

Personnel

Facilities

System Name*

Address*

City*

State*

Zip*

Telephone*

Fax

Website

Tax Status (choose one)*

Contact person completing this form

First*

Last*

Email*

Phone/extension*

Is your system part of a larger entity?*

Entity Name

Entity Address

Entity City

Entity State

Entity Zip

Entity Phone

Please review the descriptions below and choose all that describe your system and the patient populations you serve.

Description	Selected	Children	Adolescents	Adults	Older Adults
Specialty Inpatient Hospital: An organization licensed by the state and operated as a hospital primarily concerned with the provision of inpatient care to persons with mental illness or addiction
General Hospital Psychiatric Unit: A unit in a general hospital or a facility licensed as part of a general hospital that is solely dedicated to the delivery of mental health and/or substance use disorders
Residential Treatment Center - Mental Health: An organization licensed to provide overnight mental healthcare in conjunction with an intensive treatment program in a setting other than a hospital
Residential Treatment Center - Substance Use: An organization licensed to provide overnight substance use care in conjunction with an intensive treatment program in a setting other than a hospital
Partial Hospitalization Program: A planned program of mental health or substance use treatment services provided to groups of patients with three or more sessions per day
Intensive Outpatient Program: A prescribed course of mental health or substance use disorder treatment in which the patient receives outpatient care no fewer than three times a week (this may include more than one service per day)
Outpatient Center: An organization providing services outside a hospital setting
Opioid Treatment Program: An accredited treatment program with Substance Abuse and Mental Health Services Administration (SAMHSA) certification and Drug Enforcement Administration (DEA) registration to administer and dispense opioid agonist medications that are approved by the Food and Drug Administration (FDA) to treat opioid addiction
Office-Based Opioid Treatment: An Office Based Opioid Treatment (OBOT) allows primary care or general healthcare prescribers with a DATA waiver to dispense or prescribe any Controlled Substances Act (CSA) schedules III, IV, V medication approved by the FDA for the treatment of opioid use disorder
Therapeutic School: Day programs or 24-hour settings that provide an integrated environment focused on the physical, emotional, behavioral, and academic development for youth
Community Mental Health Center: A community mental health facility that provides behavioral health services; depending on the facility, these services may include inpatient and outpatient treatment, emergency care, individual and family therapy, support groups, health education, screenings, and psychosocial rehabilitation
Community Based Behavioral Health Center: A clinic certified by states in accordance with SAMHSA criteria and the requirements of the Protecting Access to Medicare Act of 2014.
Crisis Stabilization: Crisis Stabilization Centers provide suicide prevention services, address behavioral health treatment, divert individuals from entering a higher level of care, and address the distress experienced by individuals in a behavioral health crisis
Recovery Support Services: Recovery Support Services means a broad range of non-clinical services that assist individuals and families to initiate, stabilize, and maintain long-term recovery, such as but not limited to peer support, supportive employment, and mutual aid groups
Telehealth: Telehealth, sometimes called telemedicine, is the use of electronic information and telecommunication technologies to provide care when the patient and provider are not in the same place at the same time

Please add the number of beds, treatment slots, employees, and patients this system serves

Number of Inpatient Residential Beds

Number of Outpatient Treatment Slots

Number of Employees

Number of Patients Served Each Year

Please select your payor mix from the following categories by percentage:

Payor	Percentage
Medicare
Medicaid
Private Insurance
State or County Funding
Federal Military Insurance (e.g., TRICARE)
Self-pay
Charity care/scholarship
Total (This must total 100%)

Dues are based on the net revenue for all behavioral healthcare components of your system.

All information provided will be kept confidential.

Net Revenue: Gross behavioral healthcare patient care revenue minus contractual allowances, bad debt, charity care, research grants, and endowment revenue.

Timeframe for reporting revenue is the most recent fiscal year. Reporting period is*

System Net Revenue*

Please fill in total Net Revenue if it is higher than $1.3 billion

Please mail your membership-dues check to:
National Association for Behavioral Healthcare
P.O. Box 719048
Philadelphia, PA 19171-9048

Please list the names of the key behavioral healthcare leaders within your system so that we may better serve your team.

Position Title	First Name *	Last Name *	Suffix	Email *
Chief Executive Officer	*	*		*
Chief Financial Officer	*	*		*
Clinical Director	*	*		*
Government Relations Contact	*	*		*
Quality and Compliance Director	*	*		*

Please provide a list of all the facilities you operate. This list will be used to share our weekly newsletter with the CEOs of all your facilities.

Does your system have facilities?*

Please download the Excel spreadsheet to fill out by clicking here.

Please Upload the Completed Sheet of Facilities*

Change Number of Facilities

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*

Facility 1

Facility Name*

Type of Facility*

Description	Selected
Specialty Inpatient Hospital: An organization licensed by the state and operated as a hospital primarily concerned with the provision of inpatient care to persons with mental illness or addiction
General Hospital Psychiatric Unit: A unit in a general hospital or a facility licensed as part of a general hospital that is solely dedicated to the delivery of mental health and/or substance use disorders
Residential Treatment Center - Mental Health: An organization licensed to provide overnight mental healthcare in conjunction with an intensive treatment program in a setting other than a hospital
Residential Treatment Center - Substance Use: An organization licensed to provide overnight substance use care in conjunction with an intensive treatment program in a setting other than a hospital
Partial Hospitalization Program: A planned program of mental health or substance use treatment services provided to groups of patients with three or more sessions per day
Intensive Outpatient Program: A prescribed course of mental health or substance use disorder treatment in which the patient receives outpatient care no fewer than three times a week (this may include more than one service per day)
Outpatient Center: An organization providing services outside a hospital setting
Opioid Treatment Program: An accredited treatment program with Substance Abuse and Mental Health Services Administration (SAMHSA) certification and Drug Enforcement Administration (DEA) registration to administer and dispense opioid agonist medications that are approved by the Food and Drug Administration (FDA) to treat opioid addiction
Office-Based Opioid Treatment: An Office Based Opioid Treatment (OBOT) allows primary care or general healthcare prescribers with a DATA waiver to dispense or prescribe any Controlled Substances Act (CSA) schedules III, IV, V medication approved by the FDA for the treatment of opioid use disorder
Therapeutic School: Day programs or 24-hour settings that provide an integrated environment focused on the physical, emotional, behavioral, and academic development for youth
Community Mental Health Center: A community mental health facility that provides behavioral health services; depending on the facility, these services may include inpatient and outpatient treatment, emergency care, individual and family therapy, support groups, health education, screenings, and psychosocial rehabilitation
Community Based Behavioral Health Center: A clinic certified by states in accordance with SAMHSA criteria and the requirements of the Protecting Access to Medicare Act of 2014.
Crisis Stabilization: Crisis Stabilization Centers provide suicide prevention services, address behavioral health treatment, divert individuals from entering a higher level of care, and address the distress experienced by individuals in a behavioral health crisis
Recovery Support Services: Recovery Support Services means a broad range of non-clinical services that assist individuals and families to initiate, stabilize, and maintain long-term recovery, such as but not limited to peer support, supportive employment, and mutual aid groups
Telehealth: Telehealth, sometimes called telemedicine, is the use of electronic information and telecommunication technologies to provide care when the patient and provider are not in the same place at the same time

Address*

City*

State*

Zip*

Telephone

Fax

Website

Facility's Chief Executive Officer

Prefix*

First*

Last*

Suffix

Email*

Please add the number of beds, treatment slots, employees, and patients served for this facility:

Number of Inpatient Residential Beds

Number of Outpatient Treatment Slots

Number of Employees

Number of Patients Served Each Year

Clear Facility

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First Name*

Last Name*

Date*

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