Application for MARR Certification
Organizational Information
Legal Name of Organization *
Your answer
Doing Business As/Assumed Name *
Your answer
Organization Type (e.g. LLC, Corporation, sole proprietorship) *
Your answer
State of Incorporation or Organization *
Your answer
Year Founded *
Your answer
Service Location/s (County) *
Your answer
Organization's Contact Information
Phone number, e-mail address and service area will be displayed publicly once the provider is certified and in compliance. Street addresses will not be displayed.
Principal Business Address *
Your answer
Mailing Address (if different)
Your answer
Principal Contact Person and Title *
Your answer
Contact Phone (Daytime) *
Your answer
Contact Phone (Evening) *
Your answer
Contact Email *
Your answer
Website *
Your answer
Program Information
Level of support based upon NARR standards *
Required
Is this home a Men’s residence, a Woman’s residence, or do you have both? *
Program Fees/Rent per Week/Month
Your answer
Does your Agency offer the same Level of services to all of it’s homes/addresses? *
If you answered 'No' to the question above, please explain
Your answer
Total number of Homes/Residences that hold Recovery Beds *
Your answer
Total Number of Employees/Staff *
Your answer
Number of Paid Employees/Staff *
Your answer
Number of Volunteer Employees/Staff *
Your answer
Is this organization willing to adopt the NARR standards, as revised? *
Briefly describe this organization’s governance and leadership structure *
Your answer
Have you or any organization you’ve been associated with ever been charged or convicted of Medicaid Fraud or Abuse? *
If yes, please explain.
Your answer
Number of Recovery Residences Operated
Please list the total number of recovery residences operated by the organization in the State of Michigan including each physical address.
Physical Address(s) List all *
Your answer
State of Michigan License Number (if any, list in order according to your list of addresses) *
Your answer
CARF/JAYCO Accreditation Number (if any, list in order according to your list of addresses) *
Your answer
Number of Bedrooms (list in order according to your addresses) *
Your answer
Please sign your name stating that each bedroom abides by the following standard: (Minimum: 75 sq. ft. for (1) one person, 50sq. ft. for each person if (2) or more are in the room). *
Your answer
Number of Beds in Each Home (list in order according to your addresses) *
Your answer
Number of 'Full' Bathrooms (list in order according to your addresses) *
Your answer
Number of 'Half' Bathrooms (list in order according to your addresses) *
Your answer
Priority Population (e.g. LGBT, Tribal, etc.) (list in order according to your addresses) *
Your answer
Medication Assisted Treatment (MAT) Residents accepted? *
If 'No' describe nondiscriminatory rationale/explanation for inability to accept MAT residents
Your answer
Additional Items Required
Please check the following boxes as an agreement to do the following;
1) All documentation that supports your Level of NARR Standards (Level 1, 2, 3, or 4) must be attached and uploaded on the MARR website or mailed as detailed on the MARR website. *
Required
2) Company/Cashier Check or Money Order for the total number of address’s/locations must be mailed after the submission of your application. *
Required
3) General Liability Insurance that lists “MARR” as additional insured. Along with the document from your insurance company that lists all of the recovery home locations that are insured under your policy. (Gathered along with your NARR standards documentation) *
Required
4) A current background check (within the last 12 months) from “ICHAT” or any other entity that can complete a similar background check on all owners, directors and chief financial officers that handle the day-to-day operations of your organization (not to include an unpaid house manager/resident residing in the home) must be mailed after your application is submitted. *
Required
I understand that it is the expectation that all MARR Certified Programs/Organizations cooperate with MARR\NARR in efforts to resolve any complaints received by MARR or NARR about your agency and I am willing to participate and support MARR\NARR-sponsored research initiatives. Initial Below; *
Your answer
I understand that MARR has the right and option of completing confidential client interviews during or after a certification process. Initial Below; *
Your answer
I understand that along with the annual site-review MARR may conduct an unannounced site visit at any time and for any reason, or for no reason at all, at MARR’s discretion. Initial Below; *
Your answer
There is a one time $300 application and documentation review fee for new applicants. (Note – Operators previously certified do not have to pay the initial Application and Document review fee). Plus, a fee of $300 for each recovery residence/address having 16 beds or less. *For each bed over 16 an additional fee of $20 per bed will be charged. ((Example: A 20 bed home/address fee would be $380. ($300 + $20 per bed over 16 beds = $380.)) *
Your answer
Initial below stating that you understand that all supporting documentation and payment must be received before your site review will be scheduled. *
Your answer
Sign below stating that you understand that any changes to your Organization, homes/addresses after your application or Certification must be reported within 30 days of change. Example: Any closures, or opening of new locations, new contact information, etc. *
Your answer
MARR Contact Information
Contact: Jeffery W. Van Treese, President

Address: Michigan Association of Recovery Residences
370 Country Club Rd Suite B, Holland, MI 49423

Email: jvantreese@micharr.com

Phone number: (616) 312-2100

Fax number: (616) 393-2182

MARR website: www.michiganarr.com
Signature of Applicant *
Your answer
Date *
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