1) The potential waiver service provider submits the Provider Application Packet to the RRDC in the region/regions it wants to serve. The packet includes:

a. Letter of Intent describing:

1. The agency's history of providing services to individuals with disabilities and/or seniors. If this experience is limited, a description of how the agency proposes to develop the expertise to effectively provide services must be included; A list of service(s) for which the provider is seeking approval; and Identification of the RRDC region(s) and/or counties within the RRDC region where service(s) would be provided.

b. Employee Verification of Qualifications forms and resume (with appropriate experience highlighted and any applicable degree) for at least one person providing the waiver service requested.

c. Signed Original Provider Agreement Form.

d. Signed original eMedNY Provider Enrollment Form. The Category of Service 0260 needs to be completed by potential providers of Home Visits by Medical Personnel and Respiratory Therapy. All other potential providers need to complete the Category of Service 0263.

e. Signed original Disclosure of Ownership and Control Form, including:

1. A list of the Board of Directors, including any relationships that exist between Board members (e.g. spouses, children, etc.), or individuals with the same last name; and the location of the agency including street address, even if the mailing address does not include a street or road.

f. Copy of the Federal Employee Identification Number (FEIN), for example a letter from the Department of Treasury, IRS.

g. A copy of provider's licensure, certification and other requirements, as applicable, which support the requested services and satisfies the requirements of being a provider of the waiver service specified in the prospective provider application.

h. A copy of provider policies and procedures which include:

HIPAA compliance;
Safety and emergency procedures;
Human Resource (personnel) records;
Serious Reportable and Recordable Incident Reporting;
Service provision tracking system;
Plan for self-appraisal of service provision including suggestions and methods for improvements;
Participant satisfaction survey;
Recording and addressing waiver participant complaints and grievances;
Recording and addressing concerns of RRDS, QMS, SC, and DOH WMS
Record keeping/ documentation; and
Agree to comply with all of DOH certified trainings provided by the RRDC

The completed Provider Application packet must be submitted to the RRDS(s) for review and recommendations in the region/regions they will be serving. If a prospective provider is interested in providing services in more than one region, the Application Packet must be sent to each RRDC for review by the RRDS(s).

2) All forms must be submitted with original signatures to RRDC.

3) The potential provider is then interviewed by the RRDS, using a standard interview form. During the first six months of implementation, Department of Health (DOH) Waiver Management Staff and QMS may also interview potential providers using the same standard interview form. The RRDS and/or DOH Waiver Management Staff reviews the Policy and Procedure developed by the potential provider.

4) The RRDS completes the interview form. And then makes a recommendation to the DOH Waiver Management Staff. When DOD Waiver Management Staff reviews the interview form, findings will be presented to the Director of the NHTD waiver (more information may be needed).

5) DOH Waiver Management Staff reviews the recommendations of the RRDS and if it concurs, the provider is approved for participation. In situations where the potential provider is interviewed by DOH Waiver Management Staff, the Director of the NHTD waiver approves the provider for participation upon recommendation by DOH Waiver Management Staff.

6) Information is then sent to eMedNY, which enters the provider in the system. The provider receives official notification of approval, and a Billing Manual.

Any willing and qualified provider may, at any time, seek approval for adding services. If a provider seeks to be approved for additional services, the RRDS will once again interview the provider as mentioned above.

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