HomeMy WebLinkAboutExhibit 3Jeb Bush,
Governor
Shelly Brantley,
Director
District 11 Office
401 N.W. 2nd
Avenue,
Suite South 821
Miami,
Florida
33128
(305) 349.1478
Fax: (305) 349.7479
agency for persons with disabilities
State of Florida
Date: May 7, 2008
Dear Medicaid Waiver Service Provider:
Effective July 1, 2008, your Medicaid Waiver Service agreement with the Agency for Persons with Disabilities (APD)
will expire. Each provider of Medicaid Waiver services must have a signed Agreement on file in order to be authorized
to deliver services under the Home and Community Based Developmental Disabilities (HCBS) and Family and
Supported Living (FSL) Waivers. Please note that this agreement will apply to both waivers if you are enrolled as a
provider under both the HCBS and FSL Waivers.
Please review the Agreement attached. Do not change or alter the document except to complete the following
items:
❖ Page 3, section VI Official Representatives. #1. (Name, Address, Telephone Number
E-mail address)
❖ Page 3, #2 (Name, Address, Telephone Number and E-Mail address)
❖ Page 4, (bottom left) Complete the area indicated as Signed by Name, Title, and Date
There is an attachment to the Agreement if you are an:enrolled provider for transportation services that indicates your
negotiated rates for payment:: Also attached isa report formatthat is required to be submitted annually by June 1. The
following documents have been incorporated by reference
• Core Assurances as described in the current Developmental Disabilities Waiver Services Coverage
and Limitations: handbook
❖ Rate Structure documents,:: currently available on`the.APD Website at
http://apd.mytiorida,cortt/clientsl
❖ The Family and Supported). Mng Waiver services directory available at APD website
http /lapdmyf}onta com/plienfsf
❖ The Developmental Disabilities Waiiver.Services Coverage' and Limitations Handbook, which list
the requirements for Medicaid waiver provider participation and specificservices. it is available on
the Agency for Health Care: Administration web site l ttp llfloriidamedicaid.acs-inc.com.
Return the signed agreement tothe Area 11 program office taft listed below no later than June 15, 2007
Austin Dean, Human Services Program Specialist,
Developmental Disabilities Program
401 NW 2nd Avenue,:Suite
Miami, FL 33128
After final review by the Agency for Persons with Disabilities, you will be provided with a copy of the Agreement for
your records.
Thank you in advance for your attention to this matter. Should you have any questions please contact me at (305) 377-
5440 or Austin Dean, Provider Enrollment Specialist at (305) 377-5736.
Sincerely,
Grit.
Carolyn L. Eleby,
Program Operations Administrator
Cc :Evelyn Alvarez, Area 11 Program Administrator