Standard Provider Application

   ♦ EIN or SSN as indicated below
   ♦ Billing/direct pay entity with IRS reporting

Checklist

Additional Documentation

 Adult Day Services (EIN)

 X

 → Insurance Requirements

 Alternative Care Facility (ACF) (EIN or SSN)

 X

 → Alternative Care Facility Letter
  → Insurance Requirements

 Behavioral Programming (EIN)
 

 X

 Behavioral Therapies (Autism) (EIN or SSN)
 

 X

 Brain Injury (BI) Assistive Technology (EIN)
 

 X

 Children with Life Limiting Illness (CLLI)

• Home Health, Hospice, Personal Care/Homemaker Services (EIN)
• Therapy and Counseling (EIN or SSN)

 X

 Children’s Case Management (EIN)
 

 X

 Colorado Choice Transitions (CCT)

• Assistive Technology, Care Giver Education, Community Transition Services, Enhanced Nursing Services, Home Delivered Meals, Independent Living Skills Training, Intensive Case Management, Peer Mentorship, Transitional Specialized Day Rehabilitation Services (EIN)
• Dental and Vision (SSN)
• Home Modifications, Transitional Behavioral Health Supports, Transitional Substance Abuse Counseling (EIN or SSN)

 X

 → Letter of Intent

 Community Mental Health Services (BI only) (EIN or SSN)
 

 X

 Community Transition Services (EIN)
 

 X

 Day Treatment (EIN)
 

 X

 Developmental Disabilities (EIN or SSN)

• Children’s Extensive Support
• Day Habilitation Services
• Individual Residential Services & Supports, and/or
• Supported Living Services

 X

 Developmental Disabilities - Children's Habilitative Residential Program (CHRP) (EIN or SSN)
 

 X

 Developmental Disabilities - Colorado Choice Transitions (CCT) DD/SLS (EIN or SSN)
 

 X

 Developmental Disabilities - Group Home Services (EIN or SSN)

 X

 Electronic Monitoring (EIN or SSN)

 X

 → Electronic Monitoring Letter
  → Insurance Requirements

 Home Modification (EIN or SSN)

 X

 → Home Modification Letter
  → Insurance Requirements

 In-Home Support Services (IHSS) (EIN)
 

 X

 Independent Living Skills Training (EIN)
 

 X

 Non-Medical Transportation (NMT) (EIN or SSN)

 X

 → Non-Medical Transportation Letter

 Personal Care/Homemaker (EIN)

 X

 → Personal Care/ Homemaker Letter
 → Insurance Requirements

 Substance Abuse Counseling (BI only) (EIN or SSN)
 

 X

 Supported Living Program (EIN)
 

 X

 Transitional Living Program (EIN)
 

 X