Maintaining Status as a Qualified Provider

Agency Qualified Provider

Maintaining Status as a Qualified Provider

Submit the following documents via email to dds.provider.profiles@ct.gov

Description	Documents
Change in Principal of the Entity	Resume Provider Profile Correction Form Assurance Agreement-Agency Criminal Background Verification Certificate for a Change in Principal of the Entity, Connecticut Administrator, Partnership or LLC New private providers applying to become a DDS qualified provider are required to complete a Connecticut State Police criminal background check. This applies to the Principal of the entity, Connecticut Administrator, any managing partners/owners once all application documents have been accepted. IMPORTANT: YOU MUST PRINT THE COMPLETED SERVICE CODE FORM CONTAINING THE TRACKING NUMBER AND BAR CODE AND BRING IT TO THE CONNECTICUT STATE POLICE TO CONDUCT THE FINGERPRINTING PROCESS/CRIMINAL BACKGROUND CHECK. Some local police departments offer fingerprinting services (they can electronically submit the fingerprinting or may hand you the hard copy of the fingerprinting cards to bring them to the State Police). Please review CCHRS-Pre-Enrollment-User-Manual and CCHRS-Applicant-Service-Code-Form. Contact DDS.ProviderApplications@ct.gov for the SERVICE CODE Fingerprinting is by appointment only. See Connecticut State Police website: State-Police-Bureau-of-Identification Out of state providers may utilize their state agency for the criminal background check and fingerprinting process. All reports must be submitted directly to DDS at (dds.qpapenrollment@ct.gov). BE SURE TO ENTER A VALID EMAIL ADDRESS WHEN COMPLETING THE PRE-ENROLLMENT. Reports will also be electronically sent to DDS. Note: If the new staff is the designated Administrator for Connecticut, then the individual must attend the Provider Orientation within 30 days from the date of hire or when the next mandatory Orientation is offered. Failure to attend this orientation within the stated timeframe may result in the suspension of providing supports to new referrals.
Provider Name Change	Letter on company letterhead notifying DDS of name change Copy of incorporation papers from the CT Secretary of State Assurance Agreement-Agency Note: If there is a change in the ownership or partners, the Operations Center may require the reconstructed LLC or partnership to reapply as a provider.
Clinical License/Certificate Renewal	Clinical Behavioral Consultant - submit copy of current clinical license and/or BCBA certificate when renewed. Healthcare Coordination – submit copy of current clinical license when renewed.
Changes to the Provider Profile listed on the DDS website	Provider Profile Correction Form Provider Profile Correction Form - Towns
Agency with Choice	An Agency with Choice is an option for Individuals and Families who want to participate in the recruitment and supervision of staff without the responsibility of becoming the employer of record. Providers who want to become a designated Agency with Choice Vendor must submit the Agency with Choice Assurance Form and documents listed in the Agency with Choice Letter via email to dds.providerapplications@ct.gov in addition to the application documents (corporate documents and policies). Qualified Vendors who submit the signed assurance agreement and procedures will be given an Agency with Choice designation on the DDS Qualified Provider list for those services they are qualified for.