Transcription of STATE OF NEW JERSEY DIVISION OF MEDICAL ASSISTANCE …
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STATE OF NEW JERSEY DIVISION OF MEDICAL ASSISTANCE …
STATE OF NEW JERSEY DEPARTMENT OF HUMAN services DIVISION OF MEDICAL ASSISTANCE AND health services DIVISION of Developmental Disabilities (DDD) Supports Program and Community Care Program (CCP) Application package consists of: 1. Application Cover letter 2. Request for National Provider Identifier (NPI) 3. Signature Authorization Form 4. Provider Start Date Form (optional) 5. Provider Application - FD-23B (01/03/2019) 6. Provider Agreement - FD-62 7. DDD Provider Agreement - (DDD-PA 01-03-2019) 8. Disclosure of Ownership and Control Interest Statement (06/19/2012) 9. W-9 Tax Form 10. Notice to Enrollee 11. Affirmative Action Survey (optional) 12. Authorization for Automatic Payments & Deposits 13. Agreement of Understanding 14. DDD Statement of Intent (DDD-SP-SOI 01-03-2019) 15. Business Associate Agreement (HIPAA 200-B) In order to be approved as a NJ Medicaid provider for the DDD's Supports Program and Community Care Program the applicant must submit an entire completed application package (all listed forms) including the following: A completed DDD Statement of Intent (DDD/SOI - 01-03-2019) with an accurate verification code from the DIVISION 's website: along with the necessary credentials to support the service type that you are applying.
Application Cover Letter STATE OF NEW JERSEY DEPARTMENT OF HUMAN SERVICES DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES Dear Provider: Your request for a Provider Specific Enrollment Packet has been received and
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