Fillable App Hcbs (Commonwealth of Massachusetts)

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App Hcbs (Commonwealth of Massachusetts)

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The App Hcbs (Commonwealth of Massachusetts) form is 2 pages long and contains:

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  • 21 check-boxes
  • 41 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Commonwealth of Massachusetts

BROWSE COMMONWEALTH OF MASSACHUSETTS (MA) FORMS

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MassHealth Home and Community-Based
Services (HCBS) Waiver Provider
Application
For ofce use only
Date received:
______/_______/_______
Commonwealth of Massachusetts
EOHHS
www.mass.gov/masshealth
If you have questions, contact: UMass Provider Network Administration Unit • 1-855-300-7058 • ProviderNetwork@umassmed.edu
1. Provider name (please print)
2. Provider doing business address (for self employed provider please enter self employed address)
3. City 4. State 5. Zip code (enter 9-digit zip code, if known)
6. Legal entity name
7. Legal entity street address
8. City 9. State 10. Zip code (enter 9-digit zip code, if known)
11. Telephone number (daytime) 12. Cellular telephone number (optional)
13. Fax number (if available) 14. E-mail address (please print)
15. Tax ID number or SSN 16. Contact person (please print) 17. Telephone number of contact person
18. Do you currently have any Medicaid provider numbers (in addition to the one you are applying for
with this application)? yes no
Other (specify) and #: Other (specify) and #:
19. Has there been any disciplinary action against you by any licensing boards or certication bodies? yes no
If “yes,” please explain on a separate signed, dated piece of paper attached to this application.
20. Have you ever been excluded from participation in the Medicaid or Medicare program? yes no
If “yes,” please explain on a separate signed, dated piece of paper attached to this application.
21. Type of ownership (Check one.)
01—individual applicant (sole owner) 02—partnership 03—nonprot organization
04—government entity 05—corporation 06—trust
07—other (specify):
22. Indicate the services that you are applying to provide.
adult companion
assisted living services
chore services
community/residential family
training
day services
home health aide
homemaker
independent living supports
individual support/
community habilitation
occupational therapy
peer support
personal care
physical therapy
prevocational services
skilled nursing
supported employment
supportive home care aide
respite
specialized medical equipment
speech therapy
transportation
APP-HCBS (01/13)
1
(over )
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HCBS waiver provider application certication
Please Read Carefully and Sign
This is an application to be a provider in the MassHealth program. This application will become part of, and is incorporated
by reference into, the provider agreement between this applicant and MassHealth. The applicant should make and keep
a copy of this provider application as a record before submitting a signed original to MassHealth. MassHealth will retain
this provider application for its records. Moreover, the applicant should understand that it has a continuing obligation to
inform MassHealth of any change in the information submitted on or with the provider application within 14 days of the
date on which the applicant becomes aware of such change.
I certify under the pains and penalties of perjury that the information on this form and any attached statement that I have
provided has been reviewed and signed by me, and is true, accurate, and complete, to the best of my knowledge. I also
certify that I am the provider or, in the case of a legal entity, duly authorized to act on behalf of the provider. I understand
that I may be subject to civil penalties or criminal prosecution for any falsication, omission, or concealment of any
material fact contained herein.
2
Provider’s signature (signature and date stamps, or the
signature of anyone other than the provider or a person
legally authorized to sign on behalf of a legal entity, are
not acceptable)
Printed legal name of individual signing (if the provider
is a legal entity)
Date
Send your completed application to:
University of Massachusetts Medical School
Disability and Community Services
HCBS Provider Network Administration Unit
333 South Street
Shrewsbury, MA 01545
Printed legal name of provider
Title
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App Hcbs (Commonwealth of Massachusetts)

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Completed 27 July 2020

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