DEPARTMENT OF DEVELOPMENTAL SERVICES (DDS)

DEPARTMENT OF DEVELOPMENTAL SERVICES (DDS)
WAIVER SERVICES
INDIVIDUAL PRACTITIONER 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 Individual or LLC applying to lawfully establish, conduct, and provide service.

Agency Name (if applicable):     
Individual Practitioner Name:    
Address:      
City:   State:     Zip:      
FEIN # (optional) Federal Employer Tax ID Number (format xx-xxxxxxx):   Phone:       
Email:     Confirm Email:    
Organizational Structure
Choose one (1) of the following:  

2.  PROVIDER 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 that I am subject to disqualification if I knowingly make 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 I am responsible for submitting to DDS verification and documentation of my qualifications to render the Waiver Services indicated on this application.
 
Name of Individual Practitioner
 
Name of Person Submitting Application*
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 individual.
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 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. Prior approval by the Department of Developmental Services is required.
  • 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.
  • Sole proprietorships and partnerships may be required to submit records of their status as an employer.

Service  Minimum Experience
Consultant Services Healthcare Coordination
    
A Registered Nurse (RN) licensed in the State of Connecticut with:
  • at least two years of nursing experience and
  • relevant experience with people served by DDS or individuals with behavioral health needs.
Clinical Behavioral Support  
     (Check all that apply):
    Positive Behavior Supports
    Applied Behavior Analysis

Minimum experience includes two (2) years of experience providing behavioral supports to individuals with intellectual or developmental disabilities.

Positive Behavior Supports: One or more of the following:
  • Board Certified Behavior Analyst (BCBA)
  • Doctoral Degree and current licensure in psychology
  • Master’s degree in psychology, special education, social work or a related field (Proof of licensure for Licensed Clinical Social Worker, Marriage and Family Therapist or Professional Counselor).
Must include two (2) behavioral support plans that were implemented within the last year.

Applied Behavior analysis: One or more of the following:
  • Board Certified Behavior Analyst (BCBA)
  • Doctoral Degree and current licensure in psychology
  • Master’s degree in special education and current teacher certification
No work samples are required to be submitted.
 
Clinicians with one or more of the following qualifications may be considered for qualification for ABA services, upon further review of education and training:
  • Master’s degree and current licensure in social work
  • Master’s degree and current certification as a school counselor
  • Master’s degree and current licensure as a Professional Counselor
  • Master’s degree and current licensure as a Marriage and Family Therapist
Peer Support (Check all that apply):
How to manage the participants home
How to manage the self-direction of supports
How to find a job or maintain a job
How to advance in chosen career
How to access the community and build community supports
  • Minimum 21 years old
  • Possess a high school diploma or GED certificate of completion.
  • Possess a valid email address
  • Minimum 2 years of personal experience in the related area applying for.

4.  SUBMIT ADDITIONAL REQUIRED DOCUMENTS:
After submitting application, be sure to return to the "Become a DDS Qualified Provider" Home Page to submit the required Individual Practitioner Certification and the additional documents listed in the Individual Qualified Provider Checklist.
Print Completed Application
(IMPORTANT-PLEASE PRINT COMPLETED APPLICATION PRIOR TO PRESSING SUBMIT BUTTON)
Email for submission confirmation:     
Confirm email for submission confirmation: