LOUISIANA ASSOCIATION OF BEHAVIORAL HEALTH PROVIDERS- AFFILIATES

LOUISIANA ASSOCIATION OF BEHAVIORAL HEALTH PROVIDERS

Affiliate Membership Application 2021
Application Type:*

New ApplicationRenewal Application (1/2021 to 12/2021)
MISSION STATEMENT OF THE ASSOCIATION
To advocate for effective, quality behavioral healthcare treatment for Medicaid recipients in Louisiana by raising public awareness and providing a platform for exchange of ideas between consumers, providers, advocates, legislators and government for improving behavioral healthcare in the State.
EligibilityRequirements:
1.Agency must becurrently licensed by the Louisiana Department of Health (LDH) as a Behavioral Health Service Provider (BHSP) (Please upload current liscense at the bottom)
2. Must have been accredited by a national accrediting body for at least 2 years prior to applying: (Check one)*

CARFJoint CommissionCOAHombuildersOther
3. Must attest that your agency follows all current regulations in the Medicaid Behavioral Health Manual.
Agency/Organization Name:*
Contact Person:*
Title:*
Phone number:*
Address*

Mailing Address

Street Address Line 2

CityState / Province

Zipcode
Email address of Contact Person:*
example@example.com
Fax number:*
Report of Any and All Settled Convictions and/or Pending Charges

Instructions: Fully complete this section to disclose any pending charges of malpractice or any settled convictions and/or pending charges of felonies.
A. Does the business itself, owners, principles, partners and/or governing bodies, Board of Directors, or the executive/managing directors have any settled or pending charges of malpractice?

YesNo
If yes, please provide an explanation of settled and/or pending charges of malpractice
B. Does the business itself, owners, principals, partners and/or governing bodies, Board of Directors, or the executive/managing directors have any settled convictions and/or pending charges of felonies?

YesNo
If yes, please provide an explanation of conviction including name and details of the conviction such a what? when? and where?
C. Does the business itself, owners, principals, partners and/or governing bodies, Board of Directors, or the executive/managing directors ever been excluded from a government program (such as Medicare or Medicaid)?

YesNo
If yes, please provide the name and an explanation of details of the exclusion including details including details such as what? when? and where?
I attest that the above information is true and correct and is for the purpose of consideration for full membership in the Louisiana Association of Behavioral Health Providers and agree that my agency will abide by and support the mission of the LABHP. I also agree to pay monthly dues to the association for their lobbying efforts in order to attend monthly membership meetings and maintain my voting membership in the Association.
Signed: (Type name)*
Title:*
Date:*

MonthDayYear
Date
Please upload supporting documentation:

Browse Files

Cancelof
VENMO the $250 annual membership fee to:

Louisiana Assoc of Behavioral Health Providers @Patti-williams-41

OR

Mail a $250 check for annual membership fee made out to LABHP to:

Patti Williams, Treasurer
LABHP
1434 Hawn Ave., Suite 12
Shreveport, LA 71107
Should be Empty:

LOUISIANA ASSOCIATION OF BEHAVIORAL HEALTH PROVIDERS

MISSION STATEMENT OF THE ASSOCIATION

EligibilityRequirements: