DEPARTMENT OF DEVELOPMENTAL SERVICES (DDS)

DEPARTMENT OF DEVELOPMENTAL SERVICES (DDS)
WAIVER SERVICES
AGENCY APPLICATION FOR QUALIFIED PROVIDERS


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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.
  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:   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:     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:  
If the applicant has a parent corporation, please provide the following information:
Name of Corporation:
Address:
City: State: 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?  
2. Have you previously been enrolled as a Qualified Provider by another Connecticut State agency?  
     If yes, provide name of State agency:   
     Any sanctions or revocation of contracts or agreements with this agency?  
3. Have you previously been enrolled as a Qualified Provider in another state?  
     If yes, provide state(s):  
     Any sanctions or revocation of contracts or agreements with state(s)?  
4. Have you previously applied to DDS to become a Qualified Provider?  
5. Are you currently providing services funded by DDS?  
6. Are you currently a CT Medicaid Provider?  
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  
  Adult Companion
 
Individualized Day Support
 
Personal Supports
 
Respite
 
Transportation

 Individualized Home Supports  
 
Individualized Home Supports (IHS)

 Supports in a Day Program  
 
Group Day Services
 
Individualized Supported Employment
 
Senior Supports
 
Supported Employment
 
Transitional Services

 Supports in a Residential Facility  
Community Companion Home
Community Living Arrangement
Continuous Residential Service
Overnight Respite Facility
Shared Living

 Consultant Services  
Healthcare Coordination
Clinical Behavioral Consultant
 (Check all that apply)  
     Positive Behavior Supports
     Applied Behavior Analysis
Interpreter
Nutrition
 Specialized Services  
Adult Day Health
Camp
Parenting Support
Independent Support Broker (FICS)
Transportation(transportation company)
Peer Support


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: