• Certified Provider Application | Facility

    The application below is intended for facility-based services and is only a request for information, not an offer to contract. Your Application Contact will receive a written response from Scandia Wellness Systems upon receipt of this application within 10 business days.
  • Format: 000-000-0000.

  • Facility Information

  • Is your business a recognized 501(c)(3) non-profit in the United States?*
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  • Do any of the principals hold ownership, executive, or membership-level positions in other companies/organizations that offer (a) drug and alcohol addiction treatment services, (b) laboratory services, (c) billing services, or (d) online/call center drug treatment information/referral services*
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  • Does your facility operate an in-house pharmacy?*
  • Do you have urine drug testing included in your treatment rates?*
  • Do you conduct said drug testing through your own facility-owned laboratory?*
  • Do you offer any additional laboratory testing outside of the standardized drug screenings?*
  • Does your state oversight agency perform an onsite licensing survey?*
  • Date of Last Licensing Survey*
     / /
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  • Identify the organizations with which your facility is accredited:*
  • Date of Last Audit*
     / /
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  • Treatment Program Information

  • Indicate the populations treated in your program. Check all that apply:*

  • Facility's Key Treatment Providers

    Key treatment providers are defined as people who: 1. are employed in a position that requires a state, federal, or professional license; or 2. have direct oversight of anyone meeting the standard delineated in (1); or 3. anyone who has significant input on organization treatment policies.
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  • Policies and Procedures

    Please submit copies of existing written policies and procedures that reference treatment services offered or recommended, and that demonstrate a commitment to best practices, effective recovery, and continuous improvement.
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  •  Such policies should include: 

    *Intake and discharge

    *Admittance criteria

    *Discharge procedures

    *General policies

    *Resident handbook

    *Emergency Procedures

    *Partnerships/ethics

    *Referral policy

    *No kickback policy

    *Grievance policies

    *Resident search policy

    *Best practices and outcomes

    *Relapse policy, prevention and monitoring

    *Drug and dangerous items disposal policy

    *Detoxification staffing and supervision

    *Urine and breath testing policy, including frequency of testing

    *Procedures for collecting outcomes data for continuous improvement

  • Services Offered

  • Substance Abuse/Dual Diagnosis

  • SUD - Which Levels of Care?*

  • Residential / In-patient

  • Partial Hospitalization

  • Rows

  • Intensive Outpatient

  • Rows

  • Outpatient

  • Rows

  • Medication Assisted Treatment (MAT)

  • Please check all that apply:*
  • What provider types does your program utilize? Please check all that apply:*
  • Rows
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  • Mental Health Treatment

  • MH - Which Levels of Care?*

  • Residential / In-patient

  • Partial Hospitalization

  • Rows

  • Intensive Outpatient

  • Rows

  • Outpatient

  • Rows

  • Specialty Programs

    Please indicate below if your facility currently offers any of the following specialty programs. We would like to understand any special tracks or clinical programs offered for the following populations.
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  • Terms and Disclosures

  • Has your facility, its officers, or employees, including any treatment provider, or any medical practitioner associated with your company, been the subject of disciplinary action by your state regulatory authorities within the last 5 years?*
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  • Has your facility or any currently employed treatment provider(s) been the subject of, or a party to, any litigation commenced, resolved, or otherwise addressed relating to the provision of drug or alcohol addiction treatment services at any time in the last 10 years?*
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  • Scandia Wellness Systems (SWS) was founded to improve community well-being through better healthcare, promote collaboration among providers, control costs, and stay innovative in healthcare advancements.

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