Fillable New Individual Provider Application Developmental Disabilities

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New Individual Provider Application Developmental Disabilities

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The New Individual Provider Application Developmental Disabilities form is 4 pages long and contains:

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  • 20 check-boxes
  • 42 other fields

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Revised July 2019
New Individual Provider Application
Developmental Disabilities
To ensure timely processing of your application, please attach and submit the following required documents
by mail to
GA Collaborative Enrollment
P.O. Box 56324
Atlanta, GA 30343
Or
Email to GA_Enrollment@beaconhealthoptions.com
New Individual Provider Application Checklist:
Copy of LOI Completion – Invitation to Apply Letter
Completed and signed Individual Provider Application
Proof of Age (18 or older) must submit state issued Driver’s License
Copy of Commercial General Liability or Comprehensive Liability Insurance certificate in
applicant’s name, listing the State of Georgia, Department of Behavioral Health and
Developmental Disabilities as Certificate Holder.
Page 1 of 4
Revised July 2019
I. PROVIDER INFORMATION (* indicates required fields)
A. DEMOGRAPHIC INFORMATION
Last Name*
First Name*
Middle Initial
Female
Male
Mailing Address Line 1*
Mailing Address Line 2*
Telephone #: (Include Area Code)*
City*
County*
State*
Zip(9 digit)*
Fax #:
Email Address:
B. LOCATION INFORMATION
Site Name:
area code)
Address Line 1 (street address required for referral purposes)
Address Line 2
City
County
State
Zip (9 digit)
II. PROVIDER SERVICES
A. WAIVER SERVICE INFORMATION: Please indicate which waiver service(s) approved in the Letter of
Intent (LOI phase, as well as, the Category of Service NOW/COMP)
SERVICES
NOW
WAIVER
COMP
WAIVER
ADULT NUTRITION SERVICES
ADULT OCCUPATIONAL THERAPY (OT)
ADULT PHYSICAL THERAPY (PT)
ADULT SPEECH/LANGUAGE THERAPY (SLT)
COMMUNITY ACCESS – INDIVIDUAL SERVICES
BEHAVIORAL SUPPORT SERVICES
• LEVEL I
• LEVEL II
NURSING SERVICES - LICENSED PRACTICAL NURSE (LPN)
Page 2 of 4
Revised July 2019
SERVICES
NOW
WAIVER
COMP
WAIVER
NURSING SERVICES - REGISTERED NURSE (RN)
B. COUNTIES Please indicate Counties Requested:
Page 3 of 4
Revised July 2019
III. ATTESTATION
Developmental Disabilities Services:
Th
e Georgia Department of Behavioral Health and Developmental Disabilities requires that services be provided
according to the service guidelines and that you will operate in accordance with applicable standards, policies, rules
and regulations.
By s
igning below, I do hereby certify that I have accessed, reviewed and agree to comply with the terms and
conditions set forth in the following:
• Provider Manual for Community Developmental Disabilities Providers, 02-1201
• Cr
iminal History Record Check for Contractors, 04-104
• Ru
les and Regulations of Department of Behavioral Health and Developmental Disabilities - Client's
Rights (Chapter 290-4-9)
• De
partment of Community Health (DCH) Policies and Procedures Manuals, found at the following
links:
• Part I Policies and Procedures / Billing Manual
•
Part II– Policies and Procedures for COMPREHENSIVE SUPPORTS WAIVER PROGRAM
(COMP) and NEW OPTIONS WAIVER PROGRAM (NOW)
•
Part III– Policies and Procedures for COMPREHENSIVE SUPPORTS WAIVER PROGRAM
(COMP)
• Pa
rt III– Policies and Procedures for NEW OPTIONS WAIVER PROGRAM (NOW)
I u
nderstand and acknowledge that the policies and procedures manuals are amended (generally on a quarterly
basis) when either Department finds it necessary or appropriate to do so, and that it is my responsibility to check
periodically for any revisions pertaining to the delivery of or reimbursement for services rendered to eligible
individuals.
I f
urther understand that failure to abide by either Department’s policies or procedures will result in adverse actions
including, but not limited to the denial of claims, monetary recoupment, suspension of payments, suspension of
referrals, reduction of reimbursement and termination.
I certify and attest that I have reviewed the entire contents of the completed application and that the
information provided is accurate and complete. I understand that inaccurate, incomplete or omitted data
may lead to sanctions against me.
_______________
____________ _____________________________
Name of Individual (please print) Signature of Individual
_________
_________________
Date
Page 4 of 4
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New Individual Provider Application Developmental Disabilities

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Completed 16 September 2021

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