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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
Connecticut Criminal History Record Request Form 
Connecticut State Police website
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.

IMPORTANT: You must bring the Criminal History Records Request Form along with a valid state-issued photo identification card, valid driver license, or valid US passport, and the appropriate payment with you when being fingerprinted and present it to DESPP personnel. When fingerprinting is completed, bring this letter and the fingerprints back to the window where you made your payments.

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.