SECTION A REGIONAL & SERVICE EXPANSION ONLY 1. Regional Expansion: Into which Regions do you intend to expand services? Northeast Region Northwest Region Central Region Suncoast Region Southeast Region Southern Region If currently an agency provider, attach an updated Policy and Procedures and Table of Organization that of which include the planned staffing in the new Region(s). 2. Service Expansion: Please check all the new service(s) of which you are requesting to expand, then fill out Section B. Therapeutic Supports and Support Coordination Residential Services Wellness Behavior Analysis Services Support Coordination Residential Habilitation Level 1 Level 2 Level 3 (Limited, Full, Enhanced) Standard All CDC Consultant Residential Habilitation Live-In Behavior Assistant Services (Limited, Full, Enhanced) *For 1-3 Person Foster Homes Residential Habilitation Personal Supports Dietician Services Intensive Behavior Residential Habilitation Personal Supports Occupational Therapy Behavior-Focused Respite (Under 21) Specialized Medical Home Care Physical Therapy Private Duty Nursing Life Skills Development Supported Living Coaching RN LPN Life Skills Development I Residential Nursing Supplies and Equipment (Companion) RN LPN Life Skills Development II Consumable Medical Supplies Respiratory Therapy (Supported Employment) Life Skills Development III Skilled Nursing Durable Medical Equipment (Adult Day Training) and Supplies RN LPN Off Site Environmental Accessibility Transportation Skilled Respite Adaptations Personal Emergency Specialized Mental Transportation Response Systems Health Counseling Mile Trip Month All Dental Services Speech Therapy Adult Dental Services
SECTION A REGIONAL & SERVICE EXPANSION ONLY 1. Regional Expansion: Into which Regions do you intend to expand services? Northeast Region Northwest Region Central Region Suncoast Region Southeast Region Southern Region If currently an agency provider, attach an updated Policy and Procedures and Table of Organization that of which include the planned staffing in the new Region(s). 2. Service Expansion: Please check all the new service(s) of which you are requesting to expand, then fill out Section B. Support Coordination Residential Services Therapeutic Supports and Wellness Support Coordination (Limited, Full, Enhanced) Residential Habilitation Standard Behavior Analysis Services Level 1 Level 2 Level 3 All CDC Consultant (Limited, Full, Enhanced) Residential Habilitation Live-In *For 1-3 Person Foster Homes Behavior Assistant Services Personal Supports Residential Habilitation Intensive Behavior Dietician Services Personal Supports Residential Habilitation Behavior-Focused Occupational Therapy Respite (Under 21) Specialized Medical Home Care Physical Therapy Life Skills Development Supported Living Coaching Private Duty Nursing RN LPN Life Skills Development I (Companion) Supplies and Equipment Residential Nursing RN LPN Life Skills Development II (Supported Employment) Consumable Medical Supplies Respiratory Therapy Life Skills Development III (Adult Day Training) Durable Medical Equipment and Supplies Skilled Nursing RN LPN Off Site Transportation Environmental Accessibility Adaptations Skilled Respite Transportation Mile Trip Month All Personal Emergency Response Systems Specialized Mental Health Counseling Dental Services Speech Therapy Adult Dental Services
15-04-29,%20provider%20expansion%20request%20form%20updated%204-2015.docx