Provider with an Established First Steps Facility ...

1 Central Reimbursement Office Provider ENROLLMENT Attn: Indiana Provider Enrollment CSC Covansys P. O. Box 29160 Shawnee Mission KS 66201-9160 Provider Enrollment Option 2 Fax: Email: The Indiana First Steps Program does not discriminate on the basis of race, color, national origin, sex, disability or age in its programs and activities. Inquiries related to department programs may be directed to First Steps FSSA Bureau of Child Development Services, 402 West Washington Street, Room W386, Indianapolis, IN 46204; Phone: 800-441-7837. ver. 1/26/09 Provider with an Established First Steps Facility Enrollment Checklist 1.

2 Name of Provider : _____*Member NPI: _____ Name of Facility : _____Group NPI: _____ (Please be sure that all required information below is returned complete in order to expedite your enrollment with First Steps .) 2. ( ) ** CRO Provider Enrollment Form 3. ( ) *NPI 4. ( ) Rider A (All Providers must have a signed Rider A on file at CRO with the exception of physicians, DME, and family member transportation providers) -If Associate or Specialist requiring supervision (DTS will require supervision unless they can provide a letter from a previous employer documenting 1 year experience with the Birth to three population): ( ) Rider A Attachment.

3 Direct Service Provider Supervisor Agreement ( ) Copy of Supervisor s License or Credential letter (DT) 5. ( ) Copy of your current Indiana State License if required or a copy of your diploma and transcripts signifying you meet the entry level qualifications for Early Intervention Personnel. Your diploma/transcripts must show area of degree , Elementary/Early Childhood, etc. 6. ( ) Copy of an Indiana State Police Inquiry-must be ran within the last 12 months. (County and City Police Checks are not acceptable.) 7. ( ) Proof of professional & general liability insurance policies for all disciplines with the exception of translators and parent transportation providers 8.

4 ( ) Copy of Direct Service Provider Orientation Training Certificate of Completion 9. ( ) E-mail address 10. ( ) Online Access Form 11. ( ) IHCP Provider Enrollment Application Packet (Medicaid/Private Insurance Providers) Select: Provider Services Signature: _____ Date: _____ Mail all checked items along with this coversheet to the address below. We cannot accept photocopies of signed documents or signed documents via fax. Documents with original signatures must be submitted. Please submit to: Indiana First Steps Provider Enrollment c/o CSC Covansys Box 29160 Shawnee Mission KS 66201-9160 Telephone: 1-866-339-9595 Option 2 * If you are providing health related services, you must submit your NPI with this application.

5 ** If you are Medicaid eligible, you will need to submit additional enrollment paperwork to IHCP.