Specialty Provider Qualifications Checklist

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STEPS Specialty Provider Qualifications Checklist

To add or modify the services that your organization is qualified/licensed/certified to provide, please complete and submit this form along with the attached signature sheet.

Agency

Phone

Address

Agency Contact

Agency Billing Contact

Phone/Email

List of Counties Served

List one county per line

Populations Served

IDD
PD
BI
Behavioral Health

National Provider Identifier (NPI), Tax Identification Number (TIN), or Employer Identification Number (EIN)

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.

Home-Delivered Meals - S5170 U3. Meal delivery if determined cost-effective when compared to meal preparation by a personal assistant. Up to two (2) meals per day. State rate of $6.04 per meal.
Medication Reminder/Dispenser Install - T1505 U5. Monthly - T1505. Medication reminders if determined cost-effective when compared to the same task by a personal assistant. One (1) install per year.
Personal Emergency Response System (PERS) Install - S5160 U3. Monthly S5161 U3. Personal Emergency Response System (PERS) allowing participants to seek help when alone. Up to two (2) installs per year.

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 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 in the file upload field.

STEPS Provider Checklist Signature Sheet

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