Agency Qualified Provider
Maintaining Status as a Qualified Provider
Submit the following documents via email to firstname.lastname@example.org
|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.
|Provider Name Change||
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||
|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 email@example.com 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.