Affiliation Agreement Verification Check List
Calendar Year 2014

COMPLETE ONE VERIFICATION CHECKLIST FORM AND AN AFFILIATION
AGREEMENT FOR EACH TREATMENT LOCATION (please print or type)

ALL INFORMATION MUST MATCH WHAT IS LISTED IN THE AFFILIATION AGREEMENT
Treatment Site Information
Affiliate Candidate / Agency Name (as appears on DAS license)
__________________________________________________________________________
Agency/Provider Treatment Site Address: (County) ________________
DAS License # ________________________ NJSAMS # ________________________
(Street)___________________________________________________________________________
(City)_______________________ (Zip)_________________
Treatment Site Telephone #______________________________FAX #____________________________
Admissions Contact Person at Treatment Site (Name and Title)___________________________________
E-Mail Address____________________________________ Telephone#______________________________
Administrative Contact Person at Treatment Site
(Name)______________________________________________Telephone #__________________________
E-Mail Address____________________________________ FAX #______________________________
Central Office Information
Agency’s Executive Director:______________________________________________________________
Central Office Address:____________________________________________________________________
E-Mail Address:___________________________________ Telephone #:____________________________
If mailing address is different from treatment site, please list below for IDRC mailings:
(Street)___________________________________________________________________
(City)_______________________, (State)______(Zip)_________
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Affiliate Only (Non-DAS Licensed): Circle services provided at treatment site:
Early Intervention (Level 0.5)
Outpatient (Level 1)
Other Services (Specify):______________________
DAS Licensed Agency Must Include Copy of DAS License: Circle services provided at licensed location:
Early Intervention (Level 0.5)
Outpatient (Level I)
Intensive Outpatient (Level II)
Partial Care (Level II.5)
Other Services (Specify): ________________________
Initial to confirm the following are attached to your Affiliation Agreement Application
_____Written and signed statement by the agency’s Executive Director or owner conforms to and will
abide by the following as amended and supplemented and any rules adopted:
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N.J.S.A. 39:4-50 et seq., DUI Statute
N.J.A.C. 10:162, Intoxicated Driving Program Regulations
40A:9-22 et seq., Division of Addiction Services Outpatient Regulation
45:2D-1 et seq., Division of Consumer Affairs
26:2H-1 et seq., Health and Senior Services Regulations
________ Fee schedule for each Level of Care indicated to include sliding scale fee, if applicable
identify other funding sources, health insurance, etc.
________ A written description policy for each Level of Care indicated shall include treatment
philosophy, assessment process, treatment planning, self-help, family treatment resources, discharge
(continuing of care) planning, etc.
________Treatment Site hours of operation to include Day, Evening and Weekend hours for group
sessions for each level of care indicated.
________Policy information: ______ Clinical Supervision
______ Urine Drug Screen
______ Medication Assisted Therapy
________Current Insurance (Commercial) listing treatment site address
________Current Insurance (Professional liability)
________List of staff with attached resumes and copy of all current credentials/licenses. Downloads
from the State Board of Marriage and Family Therapy Examiners are not acceptable
________Submit documented proof of education and hours of experience for counselor interns leading
to CADC or LCADC status, or to another health professional license that includes work of an alcohol
and drug counseling nature within its scope of practice, without regard to changes in employment.
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CHECK LIST COMPLETED BY:
Print or Type Name and Title:
_______________________________________________________________________________________
E-Mail Address:________________________________ Telephone #_______________________________
Fax #____________________________
DATE: _____________________
Rev. 1/13
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