Get Dcwav5000 Form

Filling out the Dcwav5000 Form is an essential step for providers seeking to offer additional services under the District of Columbia Medicaid Home and Community Based Services Waiver. This guide provides a clear, step-by-step approach to complete the form efficiently and accurately.

Follow the steps to successfully complete the Dcwav5000 Form online.

1. Click ‘Get Form’ button to access the Dcwav5000 Form and open it in your preferred editing tool.
2. Enter your provider name in the designated field. Ensure the name matches the one registered with the Department on Disability Services.
3. Fill in your existing provider number. If you do not have a provider number, please refer to the appropriate guidelines for obtaining one.
4. Provide your Tax ID or Social Security number. This information is necessary for verification and processing.
5. Complete the contact information sections, including telephone, fax, email, and the name of a contact person.
6. Indicate the pay-to address by filling out the street address, city, state, and zip code fields accurately.
7. Fill in the service address with the relevant information including street address, city, state, and zip code where services will be provided.
8. Attach copies of valid state licenses and certifications that confirm your eligibility to provide the services requested.
9. Review the certification statement, confirming that all information is true and accurate. Ensure you sign and date the application.
10. After completing the form, save your changes. You may download, print, or share the document as required.

Begin filling out your Dcwav5000 Form online today to ensure a smooth application process.