Required Documents

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: ______________

AGENCY ADDRESS: _____________________________________________________________________

PROVIDER NAME: ________________________________ EMAIL: ______________________________

FACILITY NAME: _(Each facility has a separate name)____________________________________

FACILITY ADDRESS: ______________________________________________ PHONE: _____________

APPLICATION DOCUMENTS (* Required with enrollment, ** Required with Facility App.)   

____ * Letter of Intent-“Provider Applicant Access Request…Clearinghouse”                                     ____ * Provider Enrollment Application (Individual or Agency)                    , or ______ Approval.                                        ____ * AHCA Medicaid Provider Application or ____ ** approval letter                                           ____ * Articles of Organization/Incorporation, ____Paid Board Member Name & Phone   #                      ____ * 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 APPLICATION ____ **Facility Application with Budget                                          ____ **Ownership Deed or Lease with use agreement                                ____ **Floor Plan (to scale, showing room dimensions)          ____ **Calculation of Capacity (See form)                                                                 ____ **Zoning Approval and Property Appraiser Website Printout                            ____ **Fire Marshall Safety Inspection Approval                                                               ____ **Comprehensive Emergency Management Plan (CEMP)                      ____ **Sexual Offender/Predator Search Result ____ **Documentation of any prior disciplinary action (65G-2.002)                                       

APPLICANT AND EMPLOYEE DOCUMENTS (Required for all listed employees)                      ____ 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 (for any vehicle transporting clients) ____ * Driver’s History (3 years – for all staff transporting clients)

TRAINING DOCUMENTS (*Pre-service training required with Enrollment and Facility Apps) ____ * Waiver Provider Requirements ____ * ZERO TOLERANCE ____ * HIPAA ____ * HIV/AIDS/Blood Borne Pathogen ____ * 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.