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Office of Mental Health

OMH Field Offices | Patient Safety Standards Guidelines | BHSA Council

Prior Approval Review
Sample Letter of Intent
Agency Provides Mental Health Services, but Not Licensed by OMH

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Letter of Intent

Local Government Unit
Office of Mental Health Field Office
Agency name
Agency address

For projects proposed by an agency that currently provides mental health services authorized (but not licensed) by OMH.

Identify type of services:

Proposed Action: Identify type of project

Narrative: Please provide a brief description of proposed project, identifying the county/borough involved and include anticipated effective date.

Circle type of application to be submitted: EZ Prior Approval Review (PAR) / Comprehensive PAR

Chief Executive Officer (CEO)/Executive Director:

Contact Person: name & title

Telephone #:

Email address:

Comments or questions about the information on this page can be directed to the Bureau of Inspection and Certification.