PO Box 1437, Slot S530 Little Rock, AR 72203 501-682-2441
PROVIDER CONSUMER DIRECTED FORMS
CLIENT FORMS- CONSUMER DIRECTED FORMS
AAPD AGENCY FORMS
Agency Attendant Care Provider Application (NEW and RENEWAL) – Use this form if you want your agency to be certified as an Attendant Care Agency or if you Medicaid PIN is approaching expiration, and you wish to renew
Counseling Support Management (CSM) /Targeted Case Management(TCM) Provider Application - CSM/TCM service providers are responsible for: orientating Alternatives participants to the concept of consumer-direction; providing Alternatives participants with skills training on how to recruit, interview, hire, evaluate, manage or dismiss attendants; providing support services to Alternatives participants; assessing and monitoring Alternatives participants’ needs; and, providing management reports to DAAS. Agencies wanting to be certified as a Counseling Support Management/Targeted Case Management provider should complete this application. CSM/TCM service providers wanting to renew their certification as a provider should also complete this application.
Environmental Modification NEW/Annual RENEWAL Provider Application - Environmental Providers are responsible for environmental accessibility adaptations/adaptive equipment services for Alternatives participants. Individuals wanting to be certified as an Environmental Provider should complete this application. Environmental Providers wanting to renew their certification as a provider should complete this application.
Adult Day Care (ADC) - Adult Day Care facilities are licensed by the Office of Long-Term Care (OLTC) to provide care and supervision to meet the needs of four or more adults who have functional impairments for periods of less than 24 hours but more than two hours per day, in a place other than the beneficiary's own homes. To be certified by the Division of Aging and Adult Services as a provider of adult day care services in Arkansas, a provider must be a person, corporation, partnership, association or organization licensed by the Arkansas Department of Human Services, Office of Long-Term Care as a long-term adult day care facility. Providers in the designated trade area cities in states that border Arkansas must be licensed and/or certified by the appropriate state agency as an Adult Day Care Facility. Facilities wanting to be certified as a provider for these services should complete this application.
Adult Day Health Care (ADHC) - To be certified by the Division of Aging and Adult Services as a provider of Adult Day Health services in Arkansas, a provider must be a person, corporation, partnership, association or organization licensed by Arkansas Department of Human Services, Office of Long-term Care as a long-term adult day health care facility. Adult Day Health Care facilities are licensed to provide a continuing, organized program of rehabilitative, therapeutic and supportive health services, social services and activities to individuals who are functionally impaired and who, due to the severity of their functional impairment, are not capable of fully independent living. Adult Day Health Care programs provide rehabilitative and health services directed toward meeting the health restoration and maintenance needs of the beneficiary that cannot be provided by adult day care programs. Facilities wanting to be certified as a provider for these services should complete this application.
Adult Companion - Adult Companion services include non-medical care, supervision and socialization services provided to an adult who is functionally impaired. Companions may assist or supervise the individual with such tasks as meal preparation, laundry and shopping, but not perform these activities as discrete services. The provision of companion services does not entail hands-on nursing care. Providers may also perform light housekeeping tasks which are incidental to the care and supervision of the individual. This service is provided in accordance with a therapeutic goal in the plan of care, and is not diversionary in nature. Adult Companion services may be provided by a Class A or Class B home health agency licensed as a provider of home health aide services as issued by the Arkansas Department of Health or by a private care agency with a current license as a provider of personal care aid services as issued by the Arkansas Department of Health and be enrolled as an Arkansas Medicaid personal care provider. Agencies wanting to be certified as a provider for these services should complete this application.
Adult Family Home Certification Packet Instructions - This instruction booklet serves as a handy reference when completing forms and gathering documents required for completion of the certification process.
Adult Family Homes Certification Packet - Adult Family Homes provide a family living environment for adults who are functionally impaired and who, due to the severity of their functional impairments, are considered to be at imminent risk of death or serious bodily harm and, as a consequence, are not capable of fully independent living. Enrollment as an ElderChoices Adult Family Homes provider requires certification by the Department of Human Services, Division of Aging and Adult Services, as an Adult Family Home. Entities wanting to become an Adult Family Home provider should complete this application.
Chore - Chore services provide heavy cleaning and/or yard maintenance only in extreme, specific and individual circumstances when lack of these services would make the home uninhabitable. Chore services do not include small outside painting jobs, routine lawn mowing or trimming, raking or mulching of leaves for aesthetic purposes. Chore services must be provided according to the client’s written plan of care and must be prescribed by the client’s prescribing physician. Entities wanting to be certified as a Chore service provider should complete this application.
Home Delivered Meals - To be certified by the Division of Aging and Adult Services as a provider of Home-Delivered Meal services, a provider must:
A. Be a nutrition services provider whose kitchen is approved by the Department of Health and whose meals are approved by a Registered Dietitian who has verified by nutrient analysis that meals provide 33 1/3 percent of the Dietary Reference Intakes established by the Food and Nutrition Board of the National Academy of Sciences, and comply with the Dietary Guidelines for Americans and DAAS Nutrition Services Program Policy Number 206.
B. Comply with all federal, state, county and local laws and regulations concerning the safe and sanitary handling of food, equipment and supplies used in the storage, preparation, handling, service, delivery and transportation of meals.
C. If applicable, assure that the provider’s intermediate source of delivery meets or exceeds federal, state and local laws regarding food transportation and delivery.
D. Procure and have available all necessary licenses, permits and food handlers’ cards as required by law.
Entities wanting to be certified as a Home-Delivered Meal provider should complete this application.
Homemaker - Homemaker services provide basic upkeep and maintenance of the home and household assistance, such as: menu planning, meal preparation, laundry, essential shopping and errands, and simple household tasks, which may include, but are not limited to, washing windows, cleaning ceiling fans and light fixtures, cleaning the refrigerator and washing inside walls. Entities wanting to be certified as a Homemaker provider should complete this application.
Personal Emergency Response System (PERS) - Personal Emergency Response System (PERS) is a 24-hour, seven-day-a-week, in-home electronic support system that provides two-way verbal and electronic communication with an emergency control center. It enables individuals who are elderly, infirm, or homebound to secure immediate help in the event of physical, emotional or environmental emergency. To be certified by the Division of Aging and Adult Services as a PERS provider, a provider must:
A. Provide, install and maintain FCC approved equipment which meets all Underwriter Laboratories Safety Standards;
B. Designate or operate an emergency response center to receive signals and respond according to specified operating protocol;
C. Establish a response system for each client and ensure responders receive necessary instruction and training;
D. Ensure that equipment is installed by qualified individuals who also provide instruction and training to clients.
Entities wanting to be certified as a PERS provider should complete this application.
Respite - Facility-based Respite Care may be provided outside the client’s home on a short- or long-term basis by licensed residential care facilities, nursing facilities, adult day care facilities, adult day health care facilities, level II assisted living facilities and hospitals. In-home respite care may be provided by licensed personal care or home health agencies and certified homemaker agencies. Reimbursement will be made for direct care rendered according to the client’s plan of care by trained respite workers employed and supervised by certified in-home respite providers. To be certified by the Division of Aging & Adult Services as a respite provider, a provider must: hold a current Class A and/or Class B license to provide personal care or home health services as issued by the state licensing authority or a current ElderChoices homemaker certification issued by the Division of Aging & Adult Services; employ and supervise direct care staff trained and qualified to provide respite care services; and, agree to the provider assurances of the ElderChoices waiver services. In addition, providers of facility-based Respite Care services must be one or more of the following: a licensed adult day care facility, a licensed adult day health care facility, a licensed nursing facility, a licensed residential care facility, a licensed level II assisted living facility, an ElderChoices adult family homes certification or a licensed hospital and agree to the provider assurances of the ElderChoices waiver services. Entities wanting to become a Respite provider should complete this application.
TO APPLY TO MEDICAID YOU MUST CLICK ON THE LINK BELOW AND FILL OUT THE APPLICATION
Please carefully read the Medicaid Regulations for this program prior to submitting an application. Sections I, III and IV apply to all Medicaid providers. Section II pertains specifically to the AAPD Program. Providers are responsible for abiding by all sections. AAPD Regulations can be found at: