Revalidation Information for Home and Community-Based Services (HCBS) Providers

Instructions for HCBS Providers

HCBS Service Provided

Acupuncture Complementary and Integrative Health (CIH)

Specialty Code: 879

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• A DORA Acupuncturist license for each individual providing services.
• A resume for each individual providing services that demonstrates the following experience:
  • One (1) year of experience providing Acupuncture services at the rate of 520 hours per year.
    OR
  • One (1) year experience working with individuals with paralysis or other long-term physical disabilities.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

 Adapted Therapeutic Recreational Equipment/Fees - CES  

Specialty Code: 600

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Adult Day Services BI/EBD/CIH/CMHS

Specialty Code: 601

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Alternative Care Facility EBD/CMHS

Specialty Code: 602

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Assisted Living Residence License from the Colorado Department of Public Health and Environment

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Assistive Technology BI

Specialty Code: 603

• Each service location must complete a separate revalidation and pay a separate fee.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Assistive Technology CES/SLS

Specialty Code: 607

• Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
• Individuals (SSN enrollment) complete only one revalidation.
• If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	No

Behavioral Programming BI

Specialty Code: 609

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Must submit applicable licensure for Program Director to include Licensed Psychologist with demonstrated applicable experience, or LCSW, PT, OT, SLP, RN or Masters level Psychologist with demonstrated applicable experience. Must submit a copy of the license along with a resume, transcript and/or curriculum vitae for review.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Behavioral Services DD/SLS

Specialty Code: 610

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Board Certified Behavioral Analyst (BCBA) Certificate must be submitted or one of the following licenses:
  • Licensed Clinical Social Worker (LCSW)
  • Certified Rehabilitation Counselor
  • Licensed Professional Counselor (LPC)
  • Licensed Clinical Psychologist
  • Licensed Marriage and Family Therapist

If any of the above licenses are submitted (excluding BCBA Certificate), the provider must also submit:

• A resume that demonstrates a minimum of two years of experience in providing counseling to individuals with intellectual and developmental disabilities.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Benefits Planning DD/SLS

Specialty Code: 774

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

Each individual providing services must possess one of the following certificates. However, only one certificate is required to be attached to the application:

• Community Work Incentives Coordinator (CWIC) from Virginia Commonwealth University
• Community Partner Work Incentives Counselor (CPWIC) from Virginia Commonwealth University
• Work Incentive Practitioner from Cornell University Institute on Employment and Disability

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd?	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Children with LLI - Massage Therapy CLLI

Specialty Code: 613

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• A massage license through the Colorado Department of Regulatory Agencies (DORA) is required for each individual performing services. Out-of-state providers must ALSO provide a massage license from their appropriate state agency, along with their Colorado DORA license.
• EIN enrollments - Home Care Agency Class A license or Hospice license is optional.
• Providers enrolled with an EIN must submit a statement on letterhead attesting that the provider is the only person who is providing services and that he/she will not be hiring others to provide these services. If the provider has employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation. Providers enrolled with an SSN do not need to provide an attestation.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Children with LLI - Palliative/Supportive Care CLLI

Specialty Code: 614

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Hospice or Home Care Agency Class A license from the Colorado Department of Public Health and Environment (attach a copy of current license and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Children with LLI - Respite (Skilled) CLLI

Specialty Code: 615

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• One of the following licenses issued by the Colorado Department of Public Health and Environment: Home Care Agency Class A license or Hospice license.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Children with LLI - Respite (Unskilled) CLLI

Specialty Code: 616

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• One of the following licenses issued by the Colorado Department of Public Health and Environment:
  Home Care Agency Class A license
  OR
  Home Care Agency Class A or Class B license AND Personal Care/Homemaker Services certification from CDPHE
  OR
  Hospice license

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Children with LLI - Therapy and Counseling CLLI

Specialty Code: 617

• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Clinical Social Worker, Licensed Professional Counselor, Licensed Social Worker, Licensed Psychologist, Licensed Independent Social Worker, or Music Therapist Board Certification or certification as a non-denominational/Spiritual/Bereavement Counselor/Chaplain if in-state
• Licensed Clinical Social Worker, Licensed Professional Counselor, Licensed Social Worker, Licensed Psychologist, Licensed Independent Social Worker, or Music Therapist Board Certification or certification as a non-denominational/Spiritual/Bereavement Counselor/Chaplain - if out-of-state
• Providers enrolled with an EIN must submit a statement on letterhead attesting that the provider is the only person who will be providing services and that he/she will not be hiring others to provide these services. If the provider will have employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation. Sole proprietors enrolling with an SSN do not need to provide an attestation.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Children's Case Management CHCBS

Specialty Code: 618

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• A Bachelor's Degree in any field;
  OR
• Resume demonstrating five (5) years of experience in the field of Long-Term Services and Supports (LTSS), which includes Developmental Disabilities;
  OR
• Some combination of education and relevant experience appropriate to the requirements of the position demonstrated on a resume. Relevant experience is defined as: a. Experience in one of the following areas: long-term care services and supports, gerontology, physical rehabilitation, disability services, children with special health care needs, behavioral science, special education, public health or non-profit administration, or health/medical services, including working directly with persons with physical, intellectual or developmental disabilities, mental illness, or other vulnerable populations as appropriate to the position being filled; AND completed coursework and/or experience related to the type of administrative duties performed by case managers may qualify for up to two (2) years of required relevant experience.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Children's Habilitation Residential Program (CHRP)

Specialty Code: 619

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Required licensure and/or certification is dependent upon the type of CHRP service provided. The Department will contact providers once applications are in State Review.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

CHRP – Child and Youth Mentorship

Specialty Code: 882

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

Optional: Businesses/Entities in possession of the following credentials must submit a current license:

• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care License for a Child Placement Agency from the Colorado Department of Human Services.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

CHRP – Community Connector

Specialty Code: 883

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• One of the following requirements:
  • Child Care License for a Child Placement Agency from the Colorado Department of Human Services
    OR
  • Currently enrolled as a Specialty 634 Community Connector CES provider.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	Yes

CHRP - Habilitation

Specialty Code: 884

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

Please submit one of the following licenses or certifications:

• Foster Care certification or Kinship Foster Care Certification from a County Department or Child Placement Agency
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care license for a Child Placement Agency license from the Colorado Department of Human Services
• Child Care license for Group Home or Group Center from the Colorado Department of Human Services
• Currently enrolled as a 674 Residential Habilitation Services IRSS/Host Home provider.
  • Residential Habilitation Services IRSS/Host Home providers must submit a signed attestation on letterhead that states the provider will only provide CHRP Habilitation services to members 18 and older.
• County Departments please email HCPF_CHRP@state.co.us prior to submitting an application.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

CHRP - Hippotherapy

Specialty Code: 741

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Currently enrolled as a Specialty 670 Professional Services Hippotherapy CES/SLS

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	Yes

CHRP – Massage Therapy

Specialty Code: 742

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Currently enrolled as a Specialty 729 Professional Services Massage CES/SLS

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

CHRP – Movement Therapy

Specialty Code: 743

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Currently enrolled as a Specialty 672 Movement Therapy CES/SLS

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	Yes

CHRP - Respite

Specialty Code: 885

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

Please submit one of the following licenses or certifications:

• Foster Care certification or Kinship Foster Care Certification from a County Department or Child Placement Agency
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care license for a Child Placement Agency license from the Colorado Department Human Services
• Child Care license for Group Home or Group Center from the Colorado Department of Human Services
• Currently enrolled as a Specialty 676 Respite CES/SLS provider.
• County Departments please email HCPF_CHRP@state.co.us prior to submitting an application.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

CHRP – Wraparound

Specialty Code: 886

Additional Requirements:

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

Businesses (EIN enrollment only)

• Certification in a Wraparound Training Program
  • If a provider is in progress to obtain this certification, a signed attestation on letterhead must be submitted that states the provider is in progress to obtaining certification. Please include the Wraparound Coach’s information on the attestation.
  AND
• Bachelor's Degree in a human behavioral science or related field of study OR resume that demonstrates experience working with Long-Term Services and Supports (LTSS) populations, in a private or public social services agency may substitute for the required education on a year for year basis. When using a combination of experience and education to qualify, the education must have a strong emphasis in a human behavioral science field.
  Optional: Businesses/Entities in possession of the following credentials must submit a current license:
• Residential Child Care Facility/Qualified Residential Treatment Program license from the Colorado Department of Human Services
• Child Care License for a Child Placement Agency from the Colorado Department of Human Services.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Chiropractic Complementary and Integrative Health (CIH)

Specialty Code: 880

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• A DORA Chiropractic license for each individual providing services.
• A resume for each individual providing services that demonstrates the following experience:
  • One (1) year of experience providing Chiropractic services at the rate of 520 hours per year.
    OR
  • One (1) year experience working with individuals with paralysis or other long-term physical disabilities.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Community Connector CES

Specialty Code: 634

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Community Mental Health Services BI

Specialty Code: 635

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Professional Counselor (LPC), Licensed Clinical Social Worker (LCSW), Licensed Clinical Psychologist, or Certified Rehabilitation Counselor (attach a copy of current license and complete the license information in revalidation)
• Curriculum Vitae or resume for Master's or Doctoral level counselor, outlining two years of mental health counseling experience and education.
• Providers enrolled with an EIN must submit a statement on letterhead attesting that the provider is the only person who provides services and that he/she will not be hiring others to provide these services. If the provider has employees providing services, the provider must submit a list of staff and attach a copy of the current license or certification and resume for each employee. The provider must sign either attestation. Providers enrolled with an SSN do not need to provide an attestation.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Complementary and Integrative Health SCI

Specialty Code: 638

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• License(attach a copy of current license for the applicable Acupuncturist, Chiropractor, and/or Massage Therapist, and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Day Habilitation - Specialized Habilitation DD/SLS

Specialty Code: 639

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Day Habilitation-Supported Comm Conn-DD/SLS

Specialty Code:713

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Day Treatment BI

Specialty Code: 641

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Electronic Monitoring BI/EBD/CIH/CMHS

Specialty Code: 643

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Expressive Therapy - Art/Play CLLI

Specialty Code: 645

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.

Required Certifications and/or Licenses:

• License (attach a copy of current license and complete the license information in revalidation)
  • License from the Colorado Department of Regulatory Agencies (DORA) for Licensed Clinical Social Worker (LCSW), Licensed Professional Counselor (LPC), Licensed Social Worker (LSW), Licensed Independent Social Worker (LISW), or Licensed Psychologist AND resume showing one year of experience in the provision of art/play therapy to pediatric/adolescent clients OR Non-denominational/spiritual/bereavement counselor/chaplain certification AND resume showing one year of experience in the provision of art/play therapy to pediatric/adolescent clients.
• Providers enrolled with an EIN must submit a statement on letterhead attesting that the provider is the only person who provides services and that he/she will not be hiring others to provide these services. If the provider has employees providing services, the provider must submit a list of staff and attach a copy of the current license or certification and resume for each employee. The provider must sign either attestation. Providers enrolled with an SSN do not need to provide an attestation.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Expressive Therapy - Music Therapy CLLI

Specialty Code: 646

• Each business (EIN enrollment) service location must complete a separate revalidation.

• Individuals (SSN enrollment) complete only one revalidation.

• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Certification from the Certification Board for Music Therapists for each individual providing services.
• A Bachelor's, Master's or Doctorate in Music Therapy for each individual providing services.
• Providers enrolled with an EIN must submit a statement on letterhead attesting that the provider is the only person who provides services and that he/she will not be hiring others to provide these services. If the provider has employees providing services, the provider must submit a list of staff and attach a copy of the current certification for each employee. The provider must sign either attestation. Providers enrolled with an SSN do not need to provide an attestation.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

FMS/Consumer Direct Attendant Support Svc BI/EBD/CMHS/CIH/SLS

Specialty Code:702

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	Yes

Home Accessibility Adaptations - CES/SLS

Specialty Code: 648

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

A list of counties/cities served must be attached to the application. For each county/city, please attach one of the following:

• Contractor's License for counties/cities served 
  • If the Contractor's license name and address do not match the enrollment application information, please attach a signed attestation on letterhead that states the name on the Contractor's license is an employee or contractor of the enrolling provider. 
    OR
• If services do not require a Contractor's license, please attach a signed attestation on letterhead that states services provided do not require a Contractor's license
  OR
• If services are provided in a county/city that does not require a Contractor's license, please attach a signed attestation on letterhead that states the county/city served does not require a Contractor's license.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Home Delivered Meals BI/CMHS/EBD/CIH/DD/SLS

Specialty Code: 752

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• In-state providers must possess a license to operate a retail food establishment, issued by the Colorado Department of Public Health and Environment. (Attach a copy of the current license and complete the license information in revalidation.)
• Out of State providers must attach a signed attestation, on letterhead, that states the provider is enrolled in their own state's Medicaid Program as a meals provider.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Home Modifications Adaptations BI/EBD/CIH/CMHS

Specialty Code: 651

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

A list of counties/cities served must be attached to the application. For each county/city, please attach one of the following:

• Contractor's License for counties/cities served 
  • If the Contractor's license name and address do not match the enrollment application information, please attach a signed attestation on letterhead that states the name on the Contractor's license is an employee or contractor of the enrolling provider. 
    OR
• If services do not require a Contractor's license, please attach a signed attestation on letterhead that states services provided do not require a Contractor's license
  OR
• If services are provided in a county/city that does not require a Contractor's license, please attach a signed attestation on letterhead that states the county/city served does not require a Contractor's license.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Homemaker CES/SLS

Specialty Code: 652

• Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
• Individuals (SSN enrollment) complete only one revalidation.
• If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

In-Home Support Services EBD/CIH/CHCBS

Specialty Code: 656

• Each service location must complete a separate revalidation and pay a separate fee.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Home Care Agency Class A or Class B license from the Colorado Department of Public Health and Environment (attach a copy of current license and complete the license information in revalidation)
• IHSS Provider Training certificate must be submitted for current and prospective In-Home Support Services (IHSS) Agencies. Training is provided through Consumer Direct for Colorado (CDCO) via hosted webinar, and is required for the agency administrators and back-up administrators annually. For more information and to register for IHSS Provider Training, please visit the CDCO website. Department contact: Kristine Dos Santos

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Independent Living Skills Training BI

Specialty Code: 654

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Home Care Agency (HCA) Class A or Class B license from the Colorado Department of Public Health and Environment.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Life Skills Training CMHS/EBD/CIH/SLS

Specialty Code: 753

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Colorado Department of Public Health and Environment Home Care Agency Class A or Class B license is required only for providers interested in providing members training on Personal Care. (Attach a copy of the current license and complete the license information in revalidation.)
  OR
• A signed attestation on letterhead that states the provider is not providing members training on Personal Care.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Massage Therapy Complementary and Integrative Health (CIH)

Specialty Code: 881

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• A DORA Massage Therapist license for each individual providing services.
• A resume for each individual providing services that demonstrates the following experience:
  • One (1) year of experience providing Massage Therapist services at the rate of 520 hours per year.
    OR
  • One (1) year experience working with individuals with paralysis or other long-term physical disabilities.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Mental Health Transitional Living Homes CMHS

Specialty Code: 775

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered on the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Assisted Living Residence License AND certification from the Colorado Department of Public Health and Environment. Certification is not required to be attached to the application.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd?	EIN	OOS Allowed?	No	BT Allowed?	No

Mentorship SLS

Specialty Code: 659

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Non-Medical Transportation BI/EBD/CIH/CMHS

Specialty Code: 660

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Effective July 1, 2022, an IntelliRide Transportation Certificate of Compliance must be attached to Revalidation applications. For more information regarding non-medical transportation (NMT) instructions, please visit the Non-Medical Transportation (NMT) Benefit web page.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Non-Medical Transportation DD/SLS

Specialty Code: 661

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Effective July 1, 2022, an IntelliRide Transportation Certificate of Compliance must be attached to Revalidation applications. For more information regarding non-medical transportation (NMT) instructions, please visit the Non-Medical Transportation (NMT) Benefit web page.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Parent Education CES

Specialty Code: 662

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Peer Mentorship BI/CMHS/EBD/CIH/DD/SLS

Specialty Code: 754

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	Yes

Personal Care SLS

Specialty Code: 664

• Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
• Individuals (SSN enrollment) complete only one revalidation.

• If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)

• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• License (attach a copy of current license and complete the license information in revalidation) OR
  • CDPHE Home Care Agency (HCA) Class A or Class B license only required if providing hands-on care in the member's home and the agency has more than one employee.
• If CDPHE does not require a provider to obtain a Home Care Agency license for this specialty, a signed attestation on letterhead must be submitted that states one of the following:
  • Provider is an SSN provider that only has one employee
  • Provider is an EIN provider that only has one employee who provides hands-on assistance
  • Provider is an EIN provider that does not provide hands-on assistance

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Personal Care/Homemaker Services BI/EBD/CIH/CMHS

Specialty Code: 666

• Each service location must complete a separate revalidation and pay a separate fee.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Home Care Agency Class A or Class B license from the Colorado Department of Public Health and Environment

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	Yes
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Personal Emergency Response SLS

Specialty Code: 668

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Prevocational Services DD/SLS

Specialty Code: 669

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Professional Services - Hippotherapy CES/SLS

Specialty Code: 670

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Licensure to include Physical Therapist (PT), Occupational Therapist (OT), or Speech Language Pathologist (SLP), AND AHCB Hippotherapy Certification or Hippotherapy Clinical Specialist Certification for each individual providing services (attach a copy of current license and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Professional Services - Movement Therapy CES/SLS

Specialty Code: 672

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Board Certified Music Therapist certification or Dance Therapy certification (attach a copy of the certificate and complete the information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Professional Services-Massage-SLS-CES

Specialty Code:729

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Massage Therapy License for each individual providing services (attach a copy of current license(s) and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Remote Supports BI/EBD/CIH/CMHS/SLS

Specialty Code: 756

Each business (EIN enrollment) service location must complete a separate revalidation.

• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Remote Supports Training Certificate obtained by completing the Remote Supports Provider Training
• A signed attestation on letterhead that the platform used for Remote Supports is HIPAA compliant
• Policies and Procedures regarding:
  • Ensuring member privacy and HIPAA compliance
  • Rights of Participants
  • Contingency Plan for Provision of Remote Supports if Technology fails
  • Attestation that Professionals on staff may not practice outside of their respective scope
  • Maintaining an up-to-date person-centered plan for Remotes Supports service delivery

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Residential Habilitation Services - Group Home DD

Specialty Code: 673

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Community Residential Home for Persons with Developmental Disabilities License from the Colorado Department of Public Health and Environment.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Residential Habilitation Services-IRSS/Host Home DD

Specialty Code: 674

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Respite BI/EBD/CIH/CMHS

Specialty Code: 675

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Home Class Agency Class A or Class B license from the Colorado Department of Public Health and Environment (attach a copy of current license and complete the license information in revalidation)revalidation)
• Assisted Living Residence license from the Colorado Department of Public Health and Environment (attach a copy of current license and complete the license information in revalidation)
• Long Term Care license for a Nursing Facility from the Colorado Department of Public Health and Environment (attach a copy of current license and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Respite CES/SLS

Specialty Code: 676

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Colorado Department of Public Health and Environment Home Care Agency (HCA) Class A or Class B license only required if providing hands-on care in the member's home and the agency has more than one employee (attach a copy of current license and complete the license information in revalidation)
  OR
• If CDPHE does not require a provider to obtain a Home Care Agency license for this specialty, a signed attestation on letterhead must be submitted that states one of the following:
  • Provider is an SSN provider that only has one employee
  • Provider is an EIN provider that only has one employee who provides hands-on assistance
  • Provider is an EIN provider that does not provide hands-on assistance

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Specialized Med Equipment/Supplies CES/DD/SLS

Specialty Code: 677

• Each business (EIN enrollment) service location must complete a separate revalidation and pay a separate fee.
• Individuals (SSN enrollment) complete only one revalidation.
• If enrolled via an SSN rather than an EIN, please do not pay the revalidation fee (just continue on to the next page of revalidation.)
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	Yes	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	Yes	BT Allowed?	Yes

Substance Abuse Counseling BI

Specialty Code: 678

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Certified Addiction Counselor II or Psychologist License from the Colorado Department of Regulatory Agencies (DORA) (attach a copy of current license and complete the license information in revalidation)

   

• Providers enrolled with an EIN must submit a statement on letterhead attesting that the provider is the only person who provides services and that he/she will not be hiring others to provide these services. If the provider has employees providing services, the provider must submit a list of staff and attach a copy of the current license for each employee. The provider must sign either attestation. Providers enrolled with an SSN do not need to provide an attestation.

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No

Supported Employment DD/SLS

Specialty Code: 679

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Supported Living Program BI

Specialty Code: 680

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Assisted Living Residence License or Home Care Agency Class A License from CDPHE (attach a copy of the current license and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Transition Setup BI/CMHS/EBD/CIH/DD/SLS

Specialty Code: 636

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Transitional Living Program BI

Specialty Code:  682

• Each service location must complete a separate revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Assisted Living Residence License or Home Care Agency Class A License from the Colorado Department of Public Health and Environment (attach a copy of current license and complete the license information in revalidation)

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	No
Tax ID Req'd:	EIN	OOS Allowed?	No	BT Allowed?	No

Vehicle Modifications CES/SLS

Specialty Code: 685

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Vision DD/SLS

Specialty Code: 687

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• Optometry license from the Colorado Department of Regulatory Agencies (DORA) (attach a copy of current license and complete the license information in revalidation)

Risk Level:	Limited	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	Yes

Youth Day Services

Specialty Code:751

• Each business (EIN enrollment) service location must complete a separate revalidation.
• Individuals (SSN enrollment) complete only one revalidation.
• Malpractice/Liability insurance information must be entered in the application. However, proof of insurance is not a required attachment.

Required Certifications and/or Licenses:

• None

Risk Level:	Moderate	Fee Req'd?	No	NPI Req'd?	Yes
Tax ID Req'd:	SSN or EIN	OOS Allowed?	No	BT Allowed?	No