Business Name:  Business name is required

DBA (Doing Business As): If you are “doing business as” another name, please include this information in that field.  This is only for the provider’s name, not the practice location name.  Uploaded IRS documentation is required to verify DBA name.  “Doing Business As” is not a required field.   DBA name can only be entered if the individual owns 100% of the FEIN. Any value entered in this field will become the DBA name for this provider.

Authorized Agent Email Address:  The email address of the person with legal authorization to answer questions on behalf of the business. The email address must be a match to the email used in KOG (Kentucky Online Gateway) registration. There is a minimum of 5 characters required for an email address. There needs to be (@) included in the address. Web addresses (www) are not allowed in this field. May be the same or different from the Communication Email Address. Confirm this email address by re-entering it in the Confirm Authorized Agent Email Address field.

Communication Email Address: The email address where questions about the applications, or notifications should be sent. There is a minimum of 5 characters required for an email address. There needs to be (@) included in the address. Web addresses (www) are not allowed in this field. May be the same or different from the Authorized Agent Email Address. Confirm this email address by re-entering it in the Confirm Communication Email Address field.

Business Structure Type:  Select the Business Structure Type from the dropdown box

·         Profit

·         Non Profit

Business Ownership Type:  Select the Business Ownership Type from the dropdown box

·         Private Ownership- Company is owned by private shareholders

·         Public Ownership- Company issues shares for subscription by the public.  Can be government owned

Requested Effective Date:  The requested effective date is pre-populated from the Start New Maintenance page, and may be edited.

Maintenance Received Date:  The requested effective date is pre-populated from the Start New Maintenance page, and may be edited.

Substance Use Disorder (SUD) PT 03 Behavioral Health Service Organization (BHSO) Tier Selections:  

There are three tiers available for selection:  Tier 1 Mental Health, Tier 2 Outpatient SUD, and Tier 3 Residential SUD.  Can select one, two or all tiers based on services provided. Must select at least one Tier.

• All Tiers

• Must answer required question “Are you currently accredited by a Nationally Recognized Accreditation Organization?”

• If Yes, will need to select at least one of the following certifications on 2.3 Certification screen:  08 Joint Commission, 14 Commission on Accreditation of Rehab Facility, 18 Council on Accreditation of Services for Families and Children, or Other.  Certification must be Active.

• If No, must have initiated accreditation with a recognized organization prior to today’s date.  Must enter name of Accreditation Organization and initiated date.  Initiated date cannot be greater than today.  

• Tier 2: Outpatient SUD

• Must also answer required question “Are you a licensed Narcotic Treatment Program (NTP)?”

• If Yes, enter required NTP address and hours of operation on 1.15 NTP and Medication Station Addresses screen.

• If No, no action required.

• Must answer “Do you operate a Non-Methadone Clinic at the same location?”  If answer Yes, will receive warning message to “Please enroll Non-Methadone clinic as separate entity”.

Substance Use Disorder (SUD) PT 66 Behavioral Health Multi-Specialty Group Selections:  

• Must answer required question “Are you providing Substance Use Disorder Treatment (SUD)?”

• If Yes, must have Outpatient Alcohol and Other Drug Entity (AODE) license.

• If No, no action required.

Special Characters:

• The following Special Characters cannot be used in the situations below. Field properties will not allow the following characters in the box:

 For First Name, Business Name, Other name (if any):    | + \ '

 For Last Name field:    | + \ ', and numbers are not allowed

 For Comment Boxes:     <  >  ^  ~ ` + | \ / ¬ £

 For Address fields:    | + ! @ # $ ^ * ( ) ? / \ " < > & : ; _

• If you copy and paste an excluded special character, an error message will display after clicking Save & Next

• Remove excluded characters from pasted information or uploaded text in the document

Save & Next:

• When finished, click Save & Next to save the information and proceed to the next page

• Click Back to go to the previous screen without saving

• Click Exit to return to the dashboard without saving

• Note that if the information is not saved, you will lose the data on the current page