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<< Mental Health Main • Application Information to Become a Provider • Budget Forms • Annual Reports • Other PMHS Provider Forms

For private practitioners
To apply to become a mental health provider as an independent licensed mental health practitioner or group mental health practice:

1. Contact Sarah Connelly at the Carroll County Core Service Agency at (410) 876-4440.
2. Contact MAPS-MD at (410) 953-1800 or maps-md@apshealthcare.com for an application.
3. Contact Maryland Medical Assistance Administration at (410) 767-5503 to obtain a provider billing number.

For regulated programs

1. To apply to start a regulated program, please refer to the following chapters of the Code of Maryland Regulations (COMAR):
   1. Application and approval process (COMAR 10.21.16)
   2. Definitions and administrative requirements (COMAR 10.21.17)
   3. Therapeutic Nurseries (COMAR 10.21.18)
   4. Mobile Treatment Services (COMAR 10.21.19)
   5. Outpatient Mental Health Clinics (COMAR 10.21.20)
   6. Psychiatric Rehabilitation Programs (COMAR 10.21.21)
   7. Residential Rehabilitation Programs (COMAR 10.21.22)
   8. Residential Crisis Services (COMAR 10.21.26)
   9. Respite Care Services (COMAR 10.21.27)
   10. Mental Health Vocational Programs (COMAR 10.21.28)
   COMAR 10.21.16 and COMAR 10.21.17 apply to all regulated programs.
   
   
2. Contact Sarah Connellyat the Carroll County Core Service Agency to discuss gaps in service delivery, needs, etc.
   
   
3. Complete New Provider Application Material and forward to the Carroll County Core Service Agency.
   
   
4. Complete the application as specified in the appropriate chapter of COMAR and send to the:
   Office of Health Care Quality
   Bland Bryant Building
   Spring Grove Hospital Center
   55 Wade Avenue
   Baltimore, Maryland 21228
   (410) 402-8060
   
   
5. Contact Maryland Medical Assistance Administration at (410) 767-5503 to obtain a provider billing number.

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Purchase-of-service contractors must submit a DHMH 432 budget package to the Carroll County Core Service Agency at least two weeks prior to the beginning of program operations. Instructions for these form may be found here.

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Regulated Programs
COMAR 10.21.17.04 and .05 require submission of a report annually to Carroll County Core Service Agency. This link describes the material to be submitted. All reports are due to the Carroll County Core Service Agency by January 2 following the State fiscal year of operations.

Purchase-of-Service Grant-Funded Programs

1. Purchase-of-service contractors must submit an annual report of program outcomes to the Carroll County Core Service Agency by July 15 following the State fiscal year of operations. Please see Directions for Annual Reports.
2. A DHMH 440 form and DHMH 440A form, the final financial report, must be submitted to the Carroll County Core Service Agency by July 31 following the State fiscal year of operations. Instructions for this form may be found here.
3. For cost-reimbursement purchase-of-service contracts of $100,000 or greater, contractors must submit an independent financial audit by January 2 following the State fiscal year of operations. The audit must include an audit of compliance with the Department of Health and Mental Hygiene's Human Services Agreements Manual.

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