CCBHC Interest/Information Form
Please complete this survey to be added to the South Dakota CCBHC listserv.
Organization Name
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Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Name of Primary Contact
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Email Address of Primary Contact
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Role/Title of Primary Contact
Which best describes your organizations interest in the CCBHC program currently? (choose all that apply)
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Certification as a CCBHC within the next five years.
Partnership with a CCBHC or an agency considering CCBHC certification as a Designated Collaborating Organization (DCO).
Interested in learning more about CCBHCs and DCOs.
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Areas you are interested in learning more about:
Please select all areas that you are interested in knowing more about.
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CCBHC vs DCO: including general information about becoming either type of CCBHC related entity.
CCBHC Core Program Requirements: including required accreditation, required IRS designations, and Board Governance requirements.
Core Service Provision Requirements: including general service requirement and the 9 services areas.
Partnership Requirements: including required partnerships and community needs assessment required partnerships.
Care Coordination Requirements: including care coordination requirements across a provider community of care.
Other, please specify.
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Thank you for your interest in learning more about the CCBHC program in South Dakota.
On behalf of the Division of Behavioral Health, SD Department of Social Services, thank you for your interest in the CCBHC model and its implementation across South Dakota. Click "Submit" to close this form.
Additional comments (optional):
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