Thank you for expressing interest in providing services to individuals with Autism with the Office of Developmental Programs (ODP) Bureau of Supports for Autism & Special Populations (BSASP). This application is for agencies that intend to provide services through the Adult Autism Waiver (AAW).
The agency leader must complete this application. The agency leader is one person from the organization who is responsible for provider qualification requirements from the beginning to end of the process and should be the same individual who completed the Provider Applicant Orientation (PAO) Pre-Session Modules (using their unique MyODP login). Examples of agency leader are the organization’s owner, founder, president, or Chief Executive Officer. The agency leader is responsible for the following as well as other duties: Taking legal responsibility for the organization; Making decisions for the organization and establishing and implementing the organization’s policies and procedures; and Signing the ODP Medicaid Waiver Provider Agreement.
The Agency Name and Address on your FEIN, proof of address, and insurance documents must match the agency name and address registered with the Pennsylvania Department of State. If your information does not match, please do not complete the application until they do as it will not be accepted. In addition, failure to submit the requested documentation will result in your application not being accepted.
Instructions:
You are required to answer all questions. If you do not know the answer to a specific question, you are required to determine the answer to the question prior to completing the application. Certain questions will require you to upload documents or other supporting materials. Be sure to have these documents ready before you begin. Completion of the application is required before proceeding to the next steps in the enrollment and qualification phases. If you wish to return to a previous question, there is a blue upward pointing arrow enclosed within a square outline that will allow you to return to the previous question. The arrow looks like this and is at the bottom of each page to the right of the "Next" button:
Before You Begin
Please be aware: You will not be able to complete the application more than once. As a result, before starting, please review all documents you will need to upload with your application and make sure you have information available about the following for the Agency, Legal Entity, Responsible Leader, Consultant(s), or Employees of the Agency:
1. Prior License Status
2. Prohibition from providing services.
3. Prior Sanction Status
4. Criminal Convictions
5. Current felony or misdemeanor charges
6. Previous aliases or affiliations
7. Previous voluntary or involuntary ODP Provider Agreement terminations
8. Corrective Action Plan (CAP) involvement
9. Previous ODP provider work history and paid or unpaid affiliations
Uploading Documents
You will be required to upload the documents listed below at the end of the application. You must ensure that the information on all submitted documents matches information submitted within the application. For instance, the address on your FEIN must match the address registered with the Pennsylvania Department of State:
1. Agency Leader's updated resume
2. FEIN (SS-4 form) or 147C EIN Verification Letter or CP 575 Notice (The original EIN assignment notice)
3. Driver's license or state identification for the legally responsible leader of the agency. The license must be valid and not expired and other forms of identification should not be provided.
4. Proof of Workers Compensation and Commercial General Liability insurance for the agency
5. Proof of agency address5.
6. Ownership and Controlled Interest Form. This form can be found at the following site: PROMISe Provider Enrollment | Department of Human Services | Commonwealth of Pennsylvania. The form is located in the "Enrollment Forms" under the "My company had had a change of ownership or controlled interest. In this section, there is a link to the Ownership and Controlled Interest Form.
7. Certificate of Completion of the Provider Applicant Orientation Pre-Session Modules
Ensure your files are in one of the accepted formats (e.g., PDF, JPG, PNG, or DOCX). Ensure each file does not exceed the specified size limit (50mb). Upload the file where prompted. Make sure you select the appropriate file from your device. Please ensure that uploaded documents are readable in terms of image/text clarity and font size.
Once you’ve completed the application and uploaded all required documents, you will receive a confirmation upon successful submission. We appreciate your cooperation and look forward to reviewing your application.
Please note that effective January 1, 2025, agencies are not eligible to enroll and provide residential services as enrollment for new providers of these services is closed.
Failure to submit the required documentation or accurate and truthful information will result in either an application denial or the applicant waiting a period of 365 days before a new application can be submitted.
I certify that I have reviewed the information provided on MyODP, read and understand the instructions, have all required information and documents available, and that the information provided in this application is accurate and truthful. I also certify that the person completing this application is the agency leader. Finally, I understand that intentionally or knowingly submitting false information is prohibited and the Department, at its discretion, may refuse to enter into a provider agreement with my agency.
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