Provider Automated Medication Dispensary Medical equipment and supply suppliers Category(s) Equipment and Supply Suppliers (check one or both): Provider Qualifications Provider Type: License Certificate Other Standard (specify) (specify) (specify) Current business FCC registration of equipment placed in Automated license home. Medication individual’s Dispensary Equipment and Enrolled with DSPD as an authorized Supply Suppliers provider of services and supports to people with disabilities in accordance with UCA. Enrolled as a Medicaid provider. Medical Current business Enrolled with DSPD as an authorized equipment and license provider of services and supports to people supply suppliers with disabilities in accordance with UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Automated Division of Services for People with Disabilities Annually Medication Dispensary Equipment and Supply Suppliers Medical equipment Division of Services for People with Disabilities Annually and supply suppliers Speech-Language Services HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3:
Provider Category(s) (check one or both): Automated Medication Dispensary Equipment and Supply Suppliers Medical equipment and supply suppliers Provider Qualifications Provider Type: License (specify) Certificate (specify) Other Standard (specify) Automated Medication Dispensary Equipment and Supply Suppliers Current business license FCC registration of equipment placed in individual’s home. Enrolled with DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Enrolled as a Medicaid provider. Medical equipment and supply suppliers Current business license Enrolled with DSPD as an authorized provider of services and supports to people with disabilities in accordance with UCA. Enrolled as a Medicaid provider Verification of Provider Qualifications Provider Type: Entity Responsible for Verification: Frequency of Verification Automated Medication Dispensary Equipment and Supply Suppliers Division of Services for People with Disabilities Annually Medical equipment and supply suppliers Division of Services for People with Disabilities Annually Speech-Language Services HCBS Taxonomy Category 1: Sub-Category 1: Category 2: Sub-Category 2: Category 3: Sub-Category 3:
ABI_Amendment_11.3.17.docx