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STEPS
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Provider Agency Qualifications Checklist
STEPS Provider Agency Qualifications Checklist
To add or modify the services that your organization is qualified/licensed/certified to provide, please complete, sign and submit this form.
Agency
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Phone
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Agency Address
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Agency Contact
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Email
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Agency Billing Contact
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Email
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List of Counties Served
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List one county per line.
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Populations Served:
IDD
PD
BI
Behavioral Health
If you have questions about the below services,
check the Description of STEPS Agency Provider Services
.
Please check all areas your agency has training, qualifications, licenses and/or certifications for services that your agency wishes to provide to STEPS program participants.
Community Service Coordination - T1016 U3. Requires overview of curriculum and/or certification for approval from Program Manager.
Pre-Vocational Services - T2047 U3. Requires overview of curriculum and/or certification for approval from Program Manager.
Supported Employment - H2025 U3. Requires overview of curriculum and/or certification for approval from Program Manager.
Independent Living Skills Training - H2014 U3. Requires overview of curriculum and/or certification for approval from Program Manager.
Transportation - T2003 U3.
Agency-directed Personal Assistance Services - S 5125 U3.
Enhanced Services - T2025 U3. Available only with PAS.
Assistive Services - Assist. Tech/Home Mod - S5165 U3, Vehicle Mod - T2039 U3.
National Provider Identifier (NPI), Tax Identification Number (TIN), or Employer Identification Number (EIN)
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Please list any trainings, licenses and/or certificates (including dates, licensing/certifying body, license #, etc.) that support your qualifications to provide services.
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Our organization implements person-centered planning (PCP) practices (e.g., Charting the Life Course, I/DD Person-Centered Support Plans, Individual Plans for Employment, etc.). Person-centered planning is a process for selecting and organizing the services and supports that a person with a disability may need to live and work in the community. PCP should involve the individuals receiving services and support to the maximum extent possible, even if the person has a legal representative. Which person-centered model/format does your organization use?
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Our organization completes background checks on all agency employees that will be serving STEPS participants as outlined in the STEPS Program Policy Manual. Please acknowledge the following: I understand that our agency must ensure that there is no conflict of interest directing participants to our agency or organization without considering other service providers. Our agency cannot provide services for family members, relatives or friends of employees or allow employee family members or relatives to provide STEPS services for participants.
I agree.
Please download and sign the below STEPS Provider Checklist Signature Sheet and upload the signed and dated sheet here.
STEPS Provider Checklist Signature Sheet
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