Get Provider Expansion Request Form

Filling out the Provider Expansion Request Form accurately is essential for the growth of services offered by providers. This guide will provide clear, step-by-step instructions to help you complete the form online efficiently.

Follow the steps to successfully complete the Provider Expansion Request Form

1. Click the ‘Get Form’ button to obtain the form and open it in your preferred editing tool.
2. Begin by filling in the Provider Information section. Enter your business name, any 'Doing Business As' (DBA) name if applicable, and the contact information including mailing address, physical address, telephone number, tax ID, and email address.
3. Indicate whether you are a solo provider, agency provider, or treating provider by checking the relevant box. Depending on your classification, provide additional information such as your Medicaid provider ID or agency provider ID.
4. In the Required Attachments section, ensure you check off and attach all necessary documents, including the current Med-Waiver Services Agreement, provider service listing letters, liability insurance declaration page, and recent Delmarva review if available.
5. Proceed to Section A for regional and service expansion. Specify the regions into which you plan to expand services. If you are also expanding services, check the relevant new services you intend to provide and fill out Section B.
6. In Section B, provide educational information and attach required documents such as diplomas or transcripts. List any other qualifications, licensing, and experience that supports your ability to provide services.
7. Detail your current or past service provision by listing all services previously provided to individuals. Include the service type, date range, and APD area.
8. Finally, review your completed form for accuracy. Save your changes and choose to download, print, or share the form as needed.

Take action now and fill out your Provider Expansion Request Form online to enhance your service offerings.