ENROLLMENT PROCEDURES TO BECOME A PROVIDER FOR THE STATE OF CONNECTICUT HOMECARE PROGRAM

1. A request must be submitted to the Contracts Coordinator to become a Provider for the State of CT Homecare Program.
2. A New Provider Questionnaire and Tax Identification & Certification (W-9) Form is sent to the Provider.
3. The Contracts Coordinator will review the Questionnaire when returned.
4. A meeting is arranged with the potential Provider, Director, Director of Quality Assurance and Contracts Coordinator to review the Application.
5. A Provider Forms Packet consisting of two copies of the Provider Service Agreement, a State of CT Performing Provider Registration Form, the Provider Agreement Guidelines and a listing of Towns Served are sent to the Potential Provider.
6. Both copies of the Provider Service Agreement (signed) along with the State of CT Performing Provider Registration Form (signed & witnessed) and the listing of Towns Served are returned and reviewed by the Contracts Coordinator.
7. The Provider Service Agreements are sent to the AASCC Executive Director to be executed.
8. The State Rate Sheet & Registration Forms are sent to the Department of Social Services for review.
9. When approved a State Performing Provider Number is assigned to the Provider and returned to AASCC.
10. A welcome letter of Approval, fully executed Provider Service Agreement, list of Care Managers and sample billing invoice is sent to the new Provider.