A D-U-N-S number can be obtained by visiting http://fedgov.dnb.com/webform and clicking on D-U-N-S Number: the link entitled here to request your __________________________________ “Click number via the Web.” N/A is also a toll-free number: 1-866-705-5711 This question is applicable for Residential and Transportation providers only. All other providers may indicate N/A. Submit documentation received which shows organization has registered for the D-U-N-S number. In Administrative Entities Please list all AEs (Counties) in which your Question: (AE) does your organization intend to provide organization intends to provide service. services? 3) AE Name(s): __________________________________ __________________________________ What is the provider organization's Question: Administrative Entity? (This is the AE from Please use the drop down to select the which the provider supports the most number appropriate AE. of waiver participants or, for providers with Providers will be notified of their sample by no current authorizations, the AE within their AE. which your organization intends to serve the The AE is identified in the spreadsheet received 4) most waiver participants. This will also be the by AEs that identifies the provider’s sample of AE that processes your qualification individuals. AEs will be receiving this in the application). first quarter of the new fiscal year. AE Name: __________________________________ 5) In which region is the AE located? Please use the drop down to select the Question: appropriate region for your AE.
D-U-N-S Number: __________________________________ N/A A D-U-N-S number can be obtained by visiting http://fedgov.dnb.com/webform and clicking on the link entitled “Click here to request your number via the Web.” is also a toll-free number: 1-866-705-5711 This question is applicable for Residential and Transportation providers only. All other providers may indicate N/A. Submit documentation received which shows organization has registered for the D-U-N-S number. 3) Question: In Administrative Entities (AE) does your organization intend to provide services? AE Name(s): __________________________________ __________________________________ Please list all AEs (Counties) in which your organization intends to provide service. 4) Question: What is the provider organization's Administrative Entity? (This is the AE from which the provider supports the most number of waiver participants or, for providers with no current authorizations, the AE within which your organization intends to serve the most waiver participants. This will also be the AE that processes your qualification application). AE Name: __________________________________ Please use the drop down to select the appropriate AE. Providers will be notified of their sample by their AE. The AE is identified in the spreadsheet received by AEs that identifies the provider’s sample of individuals. AEs will be receiving this in the first quarter of the new fiscal year. 5) Question: In which region is the AE located? Please use the drop down to select the appropriate region for your AE.
New+Provider+Self-Assessment+and+Guidelines+2017.docx