HomeMy WebLinkAboutBack-Upapd
Rick Scott
Governor
IN IN
Barbara Palmer
Director
III IN
Southern Region
■ ■
401 NW 2nd Avenue
Suite S-811
Miami, Florida
33128
■ ■
(305) 349-1478
Fax:
(305) 377-5028
■ ■
Toll Free:
(866) APD-CARES
(866-273-2273)
1
agency for persons with disabilities
State of Florida
Dear Medicaid Waiver Provider or Provider Agency:
PLEASE READ THIS EMAIL AND FOLLOW THE INSTRUCTIONS CAREFULLY!
On June 30, 2014, your Medicaid Waiver Service Agreement with the Agency for Persons with
Disabilities (APD) will expire. You must have a signed Medicaid Waiver Services Agreement on file in
order to be authorized to continue delivery of services under the APD Home and Community Based
Developmental Services Waiver.
The Agreement document for renewal is attached. Please review and follow the instructions for
submission. Do not Change, Alter, copy or fax your Medicaid Waiver Services Agreement.
Complete the Following Specified Items Only:
Page 3, Section VI — Official Representatives, #1: Name, Telephone, Address, E-mail
address
Page 3, Section VI — Official Representatives, #2: Name, Telephone, Address, E-mail
address
- Page 4, Bottom Left: President or Principle Owner's Signature, Name, Corporate Title
and Date.
Please note: If any of the above information changed from previous agreement, please send written
explanation in a letter with signature of owner or authorized representative so that we can make the
appropriate changes to your APD and Medicaid Files. Please submit the following items to the
Southern Region Offices no later than May 31, 2014. Failure to submit your completed Medicaid
Waiver Services Agreement may result in the termination of your Medicaid Waiver Number.
1. The signed and completed original 4 page Medicaid Waiver Services Agreement as
specified above.
2. Evidence of current liability insurance as required in Section II.D. Page 2 of the
Agreement (The agreement will not be renewed without proof of insurance).
Submit all documents to:
Kirk Ryon, Regional Program Supervisor
Agency for Persons with Disabilities, Southern Region
401 NW 2nd Ave. South 811
Miami, FI. 33128
After final review by the Agency for Persons with Disabilities of your completed agreement, you will be
provided with a copy of the Medicaid Waiver Services Agreement for your records. Thank you in
advance for your attention to this matter. If you have any further questions or concerns, please do not
hesitate to contact me at: kirk.ryonAapdcares.org
Sincerely,
Regional Program Supervisor
SDDC Medicaid Contract
2014-2017
ADT
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
TOTAL
3 Yrs. Potential
38,700
38.700
38,700
38,700
38,700
38,700
38,700
38,700
38,700
38,700
38,700
38,700
>464,40Q''
�...... ....... .. .... .x
a..1....... ...
...x..._.x._.
_ea �....:..
e..x.s.r
_.. a.....a.a
a...... _..,.
....... .�.Rat_...e........e...riaa...xa_...a..
....�..
_...... ...
.. .... ...v _
..... ..... ..x..r
3 Yrs. Projected
34.830
34,830
34,830
34,830
34,830
34,830
34,830
34,830
34,830
34,830
34,830
34.830
417,960
ADT Transportation
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
.June
TOTAL
3 Yrs Potential
8,100
81O0
8,100
8,100
8,100
8,100
8,100
8,100
8,100
8,100
8,100
8,100
� t„ 7 0'
a.a.......x..a..�__....a._.._
>_.x_..c..a
..............a
��._
,.._�--a_a..._._a._
__
_-...._..a._.._.......�a_...�'.._..
_ .. _._�
_.._ . ......_
_...a...,..,..-.
.
_ . --....__- _
3 Yrs. Projected
7,290
7,290
7,290
7,290
7,290
7,290
7.290
7,290
7,290
7,290
7,290
7,290
87,480
C(
hived Income
July
Aug
Sept
Oct
Nov
Dec
Jan
Feb
Mar
Apr
May
June
TOTAL
3 Yrs. Potential
46,800
46,800
46,800
46,800
46,800
46,800
46,800
46,800
46,800
46,800
46,800
46,800
3 Yrs. Projected
42,120
42,120
42,120
42,120
42,120
42,120
42.120
42,120
42,120
42,120
42,120
42,120
505,440
C:\Users\LMorley\AppData\Local\Microsoft\Windows\Temporary Internet Files\Content.Outlook\CXE32T2N\14-17 Medicaid Waiver Projected Revenues.xlsx