service plan, but is not otherwise limited by definition in terms of duration or frequency. individualÂ’s Service Delivery Method Participant-directed as specified in Appendix E X Provider managed (check each that applies): Specify whether the service may Legally Relative Legal Guardian be provided by Responsible (check each that Person applies): Provider Specifications Provider X Individual. List types: X Agency. List the types of agencies: Category(s) Physical Therapist Home Health Agency (check one or both): Provider Qualifications Provider Type: License Certificate Other Standard (specify) (specify) (specify) Home Health Licensed Home Certified Home Under state contract with DSPD as an Agency Health Agency Health Agency authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Physical Must hold a current Certified by DSPD as Under state contract with DSPD as an Therapist professional license an authorized provider authorized provider of services and in the State of Utah of services and supports to people with disabilities in as described in the supports to people accordance with 62A-5-103, UCA. State of Utah with disabilities in Be an enrolled provider for the Utah Physical Therapy accordance with Medicaid Program Licensing Act Title UCA. BCI Check 58, Chapter 24a. Must carry malpractice insurance Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Home Health Agency Division of Services for People with Disabilities Annually Physical Therapist Division of Services for People with Disabilities Annually Consumer Preparation Services HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2:
individualÂ’s service plan, but is not otherwise limited by definition in terms of duration or frequency. Service Delivery Method (check each that applies): Participant-directed as specified in Appendix E X Provider managed Specify whether the service may be provided by (check each that applies): Legally Responsible Person Relative Legal Guardian Provider Specifications Provider Category(s) (check one or both): X Individual. List types: X Agency. List the types of agencies: Physical Therapist Home Health Agency Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Home Health Agency Licensed Home Health Agency Certified Home Health Agency Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Enrolled as a Medicaid provider Physical Therapist Must hold a current professional license in the State of Utah as described in the State of Utah Physical Therapy Licensing Act Title 58, Chapter 24a. Certified by DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Under state contract with DSPD as an authorized provider of services and supports to people with disabilities in accordance with 62A-5-103, UCA. Be an enrolled provider for the Utah Medicaid Program BCI Check Must carry malpractice insurance Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Home Health Agency Division of Services for People with Disabilities Annually Physical Therapist Division of Services for People with Disabilities Annually Consumer Preparation Services HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: