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 Individual. List types: X Agency. List the types of agencies: Category(s) Day Supports Provider (check one or both): Provider Qualifications Provider Type: License Certificate Other Standard (specify) (specify) (specify) Day Supports Site based: Certified by DSPD as Under state contract with DSPD as an Provider an authorized provider authorized provider of services and R501-2, UAC of services and supports to people with disabilities in R539-6, UAC supports to people accordance with 62A-5-103, UCA. R539-7, UAC with disabilities in (4 or more accordance with Enrolled as a Medicaid provider individuals) UCA. Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Day Supports Provider Division of Services for People with Disabilities Annually Homemaker HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope):
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): Individual. List types: X Agency. List the types of agencies: Day Supports Provider Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Day Supports Provider Site based: R501-2, UAC R539-6, UAC R539-7, UAC (4 or more individuals) 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. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Day Supports Provider Division of Services for People with Disabilities Annually Homemaker HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3: Category 4: Sub-Category 4: Service Definition (Scope):
ABI_Amendment_11.3.17.docx