The administrative head of an inpatient facility may submit an application to the Administration for admission to the program of an individual who is committed to the inpatient facility under Health-General Article, §10-632, Annotated Code of Maryland. The Administration shall provide an application form that includes the following: The statutory authority for the application; The applicant’s: Name; Address; and Telephone number; The name and address of the individual for whom the program is being requested; The criteria for admission into the program; The facts that support the applicant’s determination that the individual who is the subject of the application meets each criterion for admission to the program; and The signature and verification by a physician, psychiatrist, psychologist, psychiatric nurse practitioner, licensed certified social worker-clinical, licensed master social worker, or licensed clinical professional counselor on behalf of the inpatient facility. If the individual’s address is unknown, or the individual is homeless, the address of the inpatient facility may be used. If an application does not include the information required under §B of this regulation, the Administration may not consider the application.