DEPARTMENT OF DEVELOPMENTAL SERVICES (DDS)

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Qualified providers must meet the standards established in the Department of Developmental Services (DDS) Home and Community Based Services Waiver (HCBS). All providers must be incorporated in the United States and Connecticut.

Prior to applying, all applicants must review the following document on the DDS website to ensure the services they provide match one or more of the waiver service descriptions.   HCBS Waiver Manual I acknowledge that I have read and understand this document. *

1.	APPLICANT INFORMATION:
	Identify the partnership, corporation, or governmental agency applying to lawfully establish, conduct, and provide service.
	Name:	*
	Address:	*
	City:	*	State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *	Zip:	* *
	FEIN #:	* *	Phone:	* *
	Connecticut Administrator
	Identify the person responsible for the overall management and oversight of the services(s) to be operated in Connecticut by the applicant.

	Name:	*
	Title:	*
	Address:		*
	City:	*		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming *		Zip:	* *
	Phone:	* *		Fax Number:	* *
	Email:	* *
	Confirm Email:	* *
	Organizational Structure
	Identify the organizational structure of the applicant's governing body.
	Choose one (1) of the following: Camp For-Profit Corporation LLC Non-Profit Corporation Partnership Public Agency S-Corporation Sole Proprietorship *
	If the applicant has a parent corporation, please provide the following information:

	Name of Corporation:
	Address:
	City:		State:	Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming	Zip:	*
	Phone:	*	Fax Number:		*

2.	PROVIDER AGENCY ACKNOWLEDGEMENT:
	I certify that the information on this application is true and complete to the best of my knowledge and is made in good faith. I understand the partnership, corporation, or government agency is subject to disqualification if it knowingly makes any misstatement of fact. All statements made on this application, including employment information, are subject to verification as a condition of becoming a qualified provider.
	I understand that the provider agency is responsible for submitting to DDS verification and documentation of its qualifications to render the Waiver Services indicated on this application.

	*		*
	Name of Principal of the Entity for Provider Agency		Title
	*		*
	Name of Person Submitting Application*		Title
	Date
	*Electronic Signature: By signing this document, I attest this is my electronic signature.  I hereby certify that I am authorized to submit these documents on behalf of the organization.

3.	SERVICE INFORMATION:
	1. Have you previously been enrolled by DDS as a Qualified Provider?			No Yes	*
	2. Have you previously been enrolled as a Qualified Provider by another Connecticut State agency?			No Yes	*
	If yes, provide name of State agency:	*
	Any sanctions or revocation of contracts or agreements with this agency?			N/A Yes No	*
	3. Have you previously been enrolled as a Qualified Provider in another state?			No Yes	*
	If yes, provide state(s):	*
	Any sanctions or revocation of contracts or agreements with state(s)?			N/A Yes No	*
	4. Have you previously applied to DDS to become a Qualified Provider?			No Yes	*
	5. Are you currently providing services funded by DDS?			No Yes	*
	6. Are you currently a CT Medicaid Provider?			No Yes	*

	Note:	All supports are expected to be provided within the State of Connecticut. Applications for services provided outside of Connecticut are limited to locations within close proximity to the state borders or unique supports presently unavailable in the state. Prior approval by the Department of Developmental Services is required.
		Connecticut corporations must demonstrate compliance with the Secretary of State Requirements.
		Out of state corporations must demonstrate they are properly registered with the Connecticut Secretary of State.
		Sole proprietorships and partnerships may be required to submit records of their status as an employer.

Please select the services(s) below that you are applying to provide.* (Click the link to view minimum qualifications:  Intellectual Disability Services)

Intellectual Disability Services
Support Categories	Work Experience
Family Supports * Companion Supports Individualized Day Support Personal Supports Respite Transportation Blended Supports
Individualized Home Supports * Individualized Home Supports (IHS)
Supports in a Day Program * Group Day Services (DSO) Individualized Supported Employment Senior Supports Group Supported Employment Transitional Employment Supports Prevocational Services Customized Employment Supports
Supports in a Residential Facility * Community Companion Home Community Living Arrangement Continuous Residential Service Overnight Respite Facility Shared Living Live-In Caregiver Remote Supports
Consultant Services * Healthcare Coordination Behavioral Support Services  (Check all that apply) *      Positive Behavior Supports      Applied Behavior Analysis Interpreter Nutrition Subcontracting for Nursing Supports
Specialized Services * Adult Day Health Camp Parenting Support Independent Support Broker (FICS) Transportation(transportation company) Peer Support Assistive Technology

4.	REQUIRED ATTACHMENTS

	Please submit applicable attachments (Word or PDF; Maximum File Size: 10 mb) per the applicable Minimum Qualifications Grid below to: dds.qpapenrollment@ct.gov.
	Be sure to include: "Agency Application for Qualified Providers" in the Subject line.

Print Completed Application			(IMPORTANT-PLEASE PRINT COMPLETED APPLICATION PRIOR TO PRESSING SUBMIT BUTTON)

Email for submission confirmation:	* *
Confirm email for submission confirmation:	* *