Medicaid Waiver Provider Network Application Form
Please complete this application to join the Medicaid waiver provider network. All information should be accurate and current.
Provider Organization Name
*
Provider Type
*
Please Select
Home Health Agency
Personal Care Provider
Therapy Provider
Adult Day Services
Case Management Agency
Other
Primary Contact Name
*
Business Email
*
example@example.com
Business Phone
*
Please enter a valid phone number.
Format: (000) 000-0000.
Service Area / Counties Served
*
Waiver Services Offered
*
Personal Care
Skilled Nursing
Physical Therapy
Occupational Therapy
Speech Therapy
Adult Day Services
Case Management
Other
License or Certification Status
*
Please Select
Licensed
Certified
Pending
Not Applicable
Years in Operation
*
NPI or Tax ID (last 4 digits or non-sensitive alternative)
Briefly describe your organization’s experience with waiver or community-based services and current staff capacity.
*
Submit Application
Should be Empty: