APD Provider Enrollment Application Form – Fill Out and Use This PDF

Agency for Persons with Disabilities

Provider Enrollment Application

Instructions

SECTION A – ALL PROVIDERS

ALL providers are to complete SECTION A of the APD Provider Enrollment Application to provide waiver services under iBudget Florida. Submit the completed application to the local APD area office. To provide services in multiple areas, submit an APD Provider Enrollment Application to each area where you intend to provide services.

SECTION B – NEW PROVIDERS or PROVIDERS EXPANDING SERVICES

a)NEW applicants wishing to enroll as providers for iBudget Florida services are to complete

SECTION B.

b)CURRENT providers wishing to enroll in services for which they are not presently enrolled are to complete SECTION B.

NOTES

•Life Skills Development – Level 1 (formerly Companion), Life Skills Development – Level 2 (formerly Supported Employment) and Life Skills Development – Level 3 (formerly Adult Day Training) are NOT new services; therefore, providers who currently provide these services do NOT need to complete SECTION B.

•Personal Supports is a NEW service that combines Personal Care Assistance (PCA), In-Home Supports, Respite and Companion for individuals age 21 or older, living in their own home or family home, and also for those at least age 18 but under age 21 living independently. If you are currently enrolled in any of the four services (PCA, In-Home Supports, Respite, and Companion), you are qualified for Personal Supports in iBudget and do NOT need to complete SECTION B to enroll in Personal Supports.

SECTION A – ALL PROVIDERS

1. Geographical Limitation

In what counties do you intend to provide services? (Please list):

2. Contact Information

For iBudget Florida enrollment purposes, please provide the name and contact information of the person designated as the official representative for your business:

Name:

Address:

City/State/Zip:

3. Provider Application Designation

SOLO Provider (Applicant alone will be	AGENCY Provider (Applicant will be hiring
providing services)	others to perform services)

NOTE: The provider and employees of a provider agency must meet qualifications required to perform the specified services.

Business Name:

FEIN / SSN:	Treating Provider ID (WSC only):	_____________
	Provider Number (List both if applicable):		______

4. Check All iBudget Florida Waiver Services for Which You Are Requesting Enrollment

Agencies or individuals applying for Support Coordination shall not apply to provide any other waiver service. (For more information on the new and renamed services, please see page 5.)

	Support Coordination	Residential Services		Therapeutic Supports and
				Wellness
	Support Coordination	Residential Habilitation		Behavior Analysis Services
	(Limited - Full - Enhanced)	(Standard)
	Dental Services	Residential Habilitation		Behavior Assistant Services
		(Behavior-Focused)
	Adult Dental Services	Residential Habilitation		Dietician Services
		(Intensive Behavior)
	Life Skills Development	Residential Habilitation		Occupational Therapy
		(Live-In)
	Life Skills Development 1	Specialized Medical Home		Physical Therapy
	(Companion)	Care
	Life Skills Development 2	Supported Living Coaching		Private Duty Nursing
	(Supported Employment)
	Life Skills Development 3	Supplies and Equipment		Residential Nursing
	(Adult Day Training)
	Personal Supports	Consumable Medical		Respiratory Therapy
		Supplies
	Personal Supports	Durable Medical		Skilled Nursing
		Equipment and Supplies
	Respite – Under 21	Environmental		Specialized Mental Health
		Accessibility Adaptations		Counseling
	Transportation	Personal Emergency		Speech Therapy
		Response Systems
	Transportation

SECTION A – CERTIFICATION

I certify that all licenses, insurance policies, certificates, etc., are current and all future changes will be submitted to the APD area office(s) where I initially enrolled.

Print Name	Signature	Date

~ END OF SECTION A ~

SECTION B – NEW APPLICANTS OR CURRENT PROVIDERS

REQUESTING EXPANSION OF SERVICES

1. Education Information

List educational experiences below and the date completed. Please submit a copy of your high school or college diploma. Waiver Support Coordinators are required to submit original transcripts.

2. Other Qualifications

List other qualifications, licenses, and certificates that make the applicant qualified to perform each iBudget Florida service checked in SECTION A, #3 of this application.

Attachments You must attach a resume or employment history. All gaps in employment must be explained.

1.

2.

3.

4.

3. Current or Past Service Provision

List all current or past services actually provided by the applicant to individuals who are customers of the Agency for Persons with Disabilities, including type of service, dates (range), and APD area where provided.

4. Disenrollment

Have you ever been disenrolled from any other APD area or disenrolled from Medicaid or another

	Medicaid waiver program?		NO	YES		If YES, provide details below.
	APD Areas		Dates			Other Programs		Dates

5. New Agency or Group Provider

If the applicant is a new agency or new group provider, attach a current table of organization that contains (as appropriate to the organization) the board of directors, directors, supervisors, support staff, and all other employees (the number and type of staff available).

Attachment(s)

6. Special Requirements – Part A

All new applicants or existing providers wishing to expand enrollment to one or more of the iBudget Florida services listed below, please provide as attachments:

•A detailed description of how you will implement each service for which you are applying. Include in the description how services being provided will meet the needs and/or support the individual (person-centered).

•Explain how you will assess customer needs and how you will train or implement changes to better meet customer needs.

•Explain how you will measure success and identify additional changes needed in training and/or services.

Attachment(s)

	iBudget Florida services requiring documentation:	Residential Habilitation (Four Types)
	Life Skills Development - Level 2	Support Coordination (Limited, Full, Enhanced)
	Life Skills Development - Level 3	Supported Living Coaching

7. Special Requirements – Part B

All new applicants or existing providers wishing to expand enrollment in Residential Habilitation, Support Coordination, or Supported Living Coaching, please provide:

•A detailed description of your plan for 24-hour/7-days-a-week service

•Appropriate qualified back-up documentation

Attachment(s)

SECTION B CERTIFICATION

I certify that all licenses, insurance policies, certificates, etc., are current and all future changes will

be submitted to the APD area office(s) where I initially enrolled.

Print Name	Signature	Date

EXHIBIT A – PROVIDER EXPERIENCE

Describe your work experience in detail, beginning with your current or most recent job. Use a separate block to describe each position. Include military service (indicate rank) and job-related volunteer work, if applicable. Indicate number of employees supervised. Provide an explanation of any gaps in employment. If needed, attach additional sheets, using the same format as this sheet. Resumes are acceptable for the description of duties and responsibilities only. All other information in this section must be completed.

Name of Present or Last Employer:

Address:

Phone number:

Job Title:

Supervisor’s Name:

Months/Years of employment:

From:

To:

Hours Per Week:

Your name, if different during employment:

Duties and responsibilities:

Reason(s) for leaving:

Name of Present or Last Employer:

Address:

Phone number:

Job Title:

Supervisor’s Name:

Months/Years of employment:

From:

To:

Hours Per Week:

Your name, if different during employment:

Duties and responsibilities:

Reason(s) for leaving:

Name of Present or Last Employer:

Address:

Phone number:

Job Title:

Supervisor’s Name:

Months/Years of employment:

From:

To:

Hours Per Week:

Your name, if different during employment:

Duties and responsibilities:

Reason(s) for leaving:

		iBudget Florida Services
	Service Family		iBudget Services
			Life Skills Development Level 1
			(formerly known as Companion Services)
			Life Skills Development Level 2
	Life Skills Development		(formerly known as Supported Employment)
			Life Skills Development – Level 3
			(formerly known as Adult Day Training)
			Family and Legal Representative Training (not available yet)
			Consumable Medical Supplies
	Supplies and		Durable Medical Equipment and Supplies
	Equipment		Environmental Accessibility Adaptations
			Personal Emergency Response Systems (unit and services)
			Personal Supports
			(includes services formerly known as In-Home Supports, Respite,
	Personal Supports		Personal Care and Companion; for individuals age 21 or older, living in
			their own home or family home; also for those at least 18 but under 21
			living in their own home)
			Respite (for individuals under 21 living in their family home)
			Standard Residential Habilitation
			Behavior-Focused Residential Habilitation
	Residential Services		Intensive-Behavior Residential Habilitation
			Live-In Residential Habilitation
			Specialized Medical Home Care
			Supported Living Coaching
			Limited Support Coordination
	Support Coordination		Full Support Coordination
			Enhanced Support Coordination
			Private Duty Nursing
			Residential Nursing
			Skilled Nursing
			Dietician Services
	Therapeutic Supports		Respiratory Therapy
			Speech Therapy
	and Wellness
			Occupational Therapy
			Physical Therapy
			Specialized Mental Health Counseling
			Behavior Analysis Services
			Behavior Assistant Services
	Transportation		Transportation
	Dental Services		Adult Dental Services