Do 21 Form PDF Details

The Do 21 Form is a questionnaire that is used to measure the tone of a person's writing. It can be used for both personal and professional purposes. The form is made up of 21 questions, and it takes about 15 minutes to complete. The results of the questionnaire can help you improve your writing style, and it can also be used to identify areas in which you need to work on improving your communication skills.

Here are several facts you might want to check before using the do 21 form.

QuestionAnswer
Form NameDo 21 Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesnj abstract, nj dmv abstract, driver abstract nj, motor vehicle asbtract request form in nj

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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:

Telephone No.: (

)

 

 

 

Address:

Cell Phone No.: (

)

 

 

 

City/State/Zip:

Email Address:

 

 

 

 

Provider Enrollment Application, rev. 1, 02/28/12

Page 1 of 5 6.2

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 ~

Provider Enrollment Application, rev. 1, 02/28/12

Page 2 of 5 6.2

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.

Degree Obtained

School/College/University

Date Completed

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.

License, Registration,

or Certification

Number

Effective Date

Expiration Date

State Licensing

Agency

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.

Service

Dates (Range)

Areas

Provider Enrollment Application, rev. 1, 02/28/12

Page 3 of 5 6.2

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

 

 

 

Provider Enrollment Application, rev. 1, 02/28/12

Page 4 of 5 6.2

 

 

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

Provider Enrollment Application, rev. 1, 02/28/12

Page 5 of 5 6.2

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