Provider Profile Form

Use this form to get started as a provider, or update your current information.

Current providers can submit updated contact information via this form at any time.

New providers may complete this form after becoming certified through the Medicaid Waiver program administered through the Indiana Division of Aging, as well as obtaining a license from the Indiana State Department of Health.

For full details on the provider application process, visit the Become a Provider page.

Alternatively, you may complete a PDF Provider Profile form and send it to provider@cicoa.org.

If you have questions, please email provider@cicoa.org.

Provider Enrollment Profile

"*" indicates required fields

Section I

Legal Business Name:*

Doing Business as Name

(If applicable)

Street Address*

Street Address Address Line 2 City State ZIP Code

Mailing Address

(If different from above)

Street Address Address Line 2 City State ZIP Code

Phone

Fax

Website

Executive Director

Name*

First Last

Phone

Fax

Name/Title of Person Signing Contract

(If different from Executive Director)

Name/Title of Person Completing Form

Referral Contact Person

Name

First Last

Phone

Fax

Claims/Authorizations Contact Person

Name

First Last

Phone

Fax

Employer Tax ID #

DUNS #

[For more information: http://fedgov.dnb.com/webform]

Type of Organization

Faith-Based

For-Profit Corp

Government Entity

Limited Liability Corp

Non-Profit Corp (Upload 501(c)(3) certification letter)

Partnership

Sole Proprietorship

Support

501(c)(3) Certification Letter

Drop files here or

Max. file size: 10 MB.

Year of Incorporation/Start-Up Date

Section II

Has your agency been accredited by an outside organization?*

Yes

Which organization?

Are you licensed by the State of Indiana?*

Yes

Please provide a copy of all relevant state licenses.

Drop files here or

Max. file size: 10 MB.

Does your company carry general liability insurance in a minimum amount of $1,000,000.00 (one million)?*

Yes

A Certificate of Insurance with CICOA listed as the certificate holder must accompany this application.

Drop files here or

Max. file size: 10 MB.

Are your employees, who will handle funds or provide services relevant to a contractual relationship with CICOA, bonded and insured to protect against losses resulting from criminal acts and wrongful and negligent performance of duties?*

Yes

Please provide certificates detailing amounts of coverage.

Drop files here or

Max. file size: 10 MB.

Are you certified to provide Medicare services in Indiana?*

Yes

Are you certified to provide Medicaid services in Indiana?*

Yes

Are you certified to provide Medicaid Waiver services in Indiana?*

Yes

Are your workers employees of your agency?*

Yes

Are you an Equal Opportunity Employer?*

Yes

How do employees report time services are provided?*

Phone clock-in

Timesheet

Other

Do you have a minimum time requirement for service visits?*

Yes

Briefly describe.

Do you allow the hiring of clients' family members to provide their care?*

Yes

Briefly describe.

Are your workers supervised and evaluated?*

Yes

By whom and how often?

Do your workers receive on-going training?*

Yes

Briefly describe.

Are updates/new information shared with direct care staff?*

Yes

Briefly describe.

Do you have procedures for handling client concerns and complaints?*

Yes

Briefly describe.

Is your organization able to serve the elderly and those with disabilities regardless of age?*

Yes

If no, which population do you serve?

Are your employees allowed to transport clients?*

Yes

Briefly describe your policies for transporting clients.

Are your employees allowed to handle client funds?*

Yes

If so, briefly describe your procedures for handling client funds.

Standard Office Hours*

Describe After-Hours/On-Call Accessibility*

List Observed Holidays

Check here if your agency has the staffing capacity to provide services during evening and overnight hours if needed

Yes

Check here if your agency has the staffing capacity to provide services on holidays when office is closed

Yes

Describe methods used to determine when weather emergencies or other circumstances would cause your organization to close and force cancellation of client services and how clients will be informed of cancellations (please provide written agency procedures)*

CICOA Aging & In-Home Solutions requires provider agencies to provide back up for staff unable to be at their assignments for any reason. Describe your policies regarding back up (please provide written agency procedures)*

Please mark the counties in which you intend to provide services*

Boone

Hamilton

Hancock

Hendricks

Johnson

Marion

Morgan

Shelby

Is your office location wheelchair accessible?*

Yes

Is your office location near public transit?*

Yes

How should people contact you?*

Phone

Referrals

Walk-In

Website

Are services available to clients who speak languages other than English?*

Yes

If yes, please list other languages.

Please provide the private pay rates for your services. Keep in mind that the private pay rate should not be any lower than the rate paid for Medicaid waiver and/or CHOICE clients.*

Is your organization a minority-owned agency?

Yes

Is your organization a woman-owned agency?

Yes

Section III

Please indicate which services your agency intends to provide under CHOICE, SSBG and Title III funding. All rates listed below are caps. Each service may be provided at a lower rate. Please indicate in the Additional Comments section the rate to be charged if lower than the cap. Rates effective beginning 2/1/2020.

AD1 - Category 1 Level 1 - Adult Day Service

Unit Rate: $2.82 - Unit of Measure: 0.25 HR