APS will set up a Google Drive folder for your required documents. You will upload documents for review and submission. The following checklist shows what is needed for every person on your roster and/or who will be in contact with clients.
————————————————————————————————————NEW APPLICATION CHECKLIST
AGENCY NAME: ___________________________________________________ DATE: ______________
PROVIDER NAME: ________________________________ EMAIL: ______________________________
FACILITY NAME: _(Each facility has a separate name)____________________________________
ADDRESS: ______________________________________________ PHONE: ____________________
APPLICATION DOCUMENTS (* Required with enrollment, ** Required with Facility App.)
All Service Providers Applications
____ * Letter of Intent-“Provider Applicant Access Request…Clearinghouse”
____ * Provider Enrollment Application (Individual or Agency)
____ * AHCA Medicaid Provider Application or * approval letter
____ * Articles of Organization, ____ Paid Board Member Names & Phone #s
____ * Sunbiz.org printout
____ * Copy of IRS form with Federal Tax ID number (SS-4)
____ * Financial Capability (Voided Check and Bank Statement showing accessability to two months of expenses.)
____ * Policy and Procedure Manual
____ * Liability Insurance Declaration Page (APD “Certificate Holder”)
Facility Applications
____ Facility Application with Budget (** Required with App,)
____ **Ownership Deed or Lease with use agreement
____ **Floor Plan (to scale, showing bedroom window opening size)
____ **Calculation of Capacity
____ **Zoning Approval and Property Appraiser Printout
____ **Fire Marshall Inspection Approval
____ **Comprehensive Emergency Management Plan (CEMP)
____ **Sexual Offender/Predator Search Result
APPLICANT AND BACKUP/EMPLOYEE DOCUMENTS
____ Employment Application (For employees)
____ * Resume/CV (must have at least 1yr related experience)
____ * Social Security Card
____ * Education proof (at least H.S. Grad Equivalency/GED)
____ * Character References (3)
____ * Verification of related experience/employment (2 references – see form)
____ * Criminal Background Screening
____* Clearinghouse/FDLE (Level II)
____ * Local Law Enforcement (Sheriff in any jurisdiction living in last 6 months)
____ * Attestation of Good Moral Character
____ * Driver’s License
____ * Vehicle Registration/Insurance,
____ * Driver’s History (Required for applicant and backup, and for other staff if transporting clients)
TRAINING DOCUMENTS ( * Pre-service training certificates required with Enrollment and Facility Applications
____ * Waiver Provider Requirements
____ * ZERO TOLERANCE
____ * HIPAA
____ * HIV/AIDS/Blood Borne Pathogens
____ * Direct Care Core Competencies (Choices and Rights, A/N/E, etc.)
____ * First Aid/CPR
____ Person-Centered Outcomes
____ Behavioral Emergency Procedures (BF/IB facilities also need Behavior Assistant and Crisis Intervention training)
____ Incident Reporting
____ Medication Administration (Required for anyone who administers meds)
____ Medication Administration Validation (Must be updated annually)
____ * Professional Certification(s)/License(s) (ie: MD, RN, LPN, CNA, etc.)
See the APD Individual Budgeting Waiver Services Coverage and Limitations Handbook https://apd.myflorida.com/ibudget/docs/iBudget%20Handbook%20with%20ADT%20Redesign%20Final.pdf for the frequency or intervals of required training.
All documents must be current, legible, and the file must be in Word or .pdf format. APD does not accept any other formats, including cell phone pictures. Certified translation may be required for foreign language documents.
All Provider Services LLC 