Admin: BH-AI Council Vendor Intake Form | National Behavioral Health Association of Providers (NBHAP)

Project Request

Submission instructions:
Complete all sections. Attach documents where requested. Incomplete submissions are deferred.

Section 1 — Vendor & Product Identification

Contact Information

Vendor Legal Name *

DBA/Product Brand Name

Primary Contact Name *

Primary Contact Name

First Name

Last Name

Primary Contact Title

Primary Contact Email *

Primary Contact Phone Number *

Company Headquarters Address *

Website / Product Link *

Years in Operation

Current Behavioral Health Customers? *

List Three

Section 2 — Intended Use & Risk Classification

1. Describe the product in 2–3 sentences. *

Primary intended use (choose all that apply): *

Administrative / Operations

Documentation / Clinical Support

Patient Engagement

Clinical Decision Support

Digital Therapeutic / Adaptive Treatment

Does the product generate clinical recommendations or risk scores?

Describe:

Select your self-identified risk tier:

Provide rationale for tier selection.

Section 3 — Model & Technical Overview

Model type(s) (LLM, predictive ML, rules+ML hybrid, etc.)

Inputs used (text notes, assessments, audio, claims data, etc.)

Outputs produced:

Human-in-the-loop design:

Where does clinician/admin review occur?

Can outputs be overridden?

Known limitations / “do not use for” list:

Model update cadence (monthly/quarterly/on-demand)

Version control + change notification process:

Explainability method:

Attach: Technical overview PDF (max 10 pages).

Maximum file size: 104.86MB

Section 4 — Data Handling, HIPAA, and 42 CFR Part 2

Does the product handle PHI?

Is a HIPAA BAA offered? (attach template)

Maximum file size: 104.86MB

Data storage location(s):

File Upload

Maximum file size: 104.86MB

Encryption: at rest / in transit (describe)

Access controls & role-based permissions:

Retention & deletion policy: (attach)

Maximum file size: 104.86MB

Training on customer data?

Explain.

If SUD records may be used, describe 42 CFR Part 2 safeguards:

Attach: Security/Privacy whitepaper, SOC2/ISO report if available.

Maximum file size: 104.86MB

Section 5 — Clinical Safety & Evidence (required for Mod/High)

Clinical claims made (exact wording):

Evidence summary:

BH/SUD-specific testing completed? (describe)

Safety risk analysis:

Escalation / emergency protocols for patient-facing tools:

FDA / regulatory status (if applicable):

Attach: Evidence packet (studies, pilots, posters, etc.).

Maximum file size: 104.86MB

Section 6 — Equity & Bias

Bias testing performed?

Attach results.

Maximum file size: 104.86MB

Subgroup performance reporting available?

Mitigation plan if disparities found:

Accessibility features (languages, ADA accommodations, low-literacy design)

Section 7 — Implementation & Support

Integration options: EHRs / APIs / SSO (list)

Average implementation time:

Training provided to providers: (attach outline)

Maximum file size: 104.86MB

Monitoring dashboard for providers: (describe + screenshots)

Maximum file size: 104.86MB

Support SLAs: response times, uptime.

Section 8 — Marketing & Ethics Attestation

Check each box: *

All marketing claims match provided evidence.

Product does not encourage unsafe clinical action without clinician review.

Product does not target or exploit vulnerable populations.

Vendor will notify NBHAP within 10 business days of major model updates

Vendor will notify NBHAP within 10 business days of safety incidents

Vendor will notify NBHAP within 10 business days of breaches

Vendor will notify NBHAP within 10 business days of regulatory actions

Vendor consents to annual re-review as condition of listing.

Signature and date

Clear

Section 9 — Post-Approval Listing Options

(Completed only if approved)

Opt-in to NBHAP AI Approved Product Registry:

Opt-in to NBHAP Associate Member Directory:

Payment is for listing/maintenance only and does not influence approval decisions.

Signature *

Clear

Type the name in the signature *

Date *

Clear

If you are human, leave this field blank.

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We are the leading and unifying voice of addiction-focused treatment programs.

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