DDSD Developmental Disability and Medically Fragile Waiver Applications

The Provider Enrollment Application and Renewal Packets are available for interested providers to download. Be sure that all paperwork in the application is filled out completely and accurately.

Please review the DDSD Waiver Standards for services about which you are inquiring, and review the other links that are provided under the Important Links portion below. Include all requested documentation with the application to avoid delay or denial of your application. If you have any questions about the application, please feel free to email us. If the email does not function, just cut and paste this email address (cpb.peu@state.nm.us) to your email program.

Provider Enrollment Application

You may obtain these forms below (note: download times may vary):

Application Here - (updated: 5/2013) If you have additional questions please contact the Provider Enrollment Unit (505-476-8910)

REQUIRED

NEW Provider Application Forms Here (updated: 5/2013)

RENEWING Provider Application Forms Here (updated: 5/2013)

 

Provider Agreement Amendment - Nov. 29, 2012

Provider Self-Imposed Moratorium Form - Jul 28, 2011

DDSD Request for Approval for Behavioral Support Consultants (BSCs) Subcontractor and Employees - Sep 22, 2011

DDSD Request for Subcontract Approval Form- (updated: 2/1/2013)

 

Important Links for Provider Enrollment Application Packet

Affiliated Computer Systems - Watts: 800-299-7308, Alb. (505) 746-9988
Billing Rates for DD and MF (MF link is not working as of 9/12/2011)
 Commission on Accreditation of Rehabilitation Facilities (CARF)
DDSD Policy and Procedures
DDSD Regional Office Contacts
DDSD Sample Provider Agreement - effective Jan 1, 2010
DDSD Standards for the Developmental Disabilities Waiver and the Medically Fragile Waiver
DHI Incident Management
DHI Incident Management Guide

Employee Abuse Registry

NMAC TITLE 7 CHAPTER 1 PART 12 EMPLOYEE ABUSE REGISTRY

NMAC TITLE 7 CHAPTER 1 PART 9 Caregivers Criminal History Screening Program (CCHSP)

NM Taxation and Revenue Department
OSHA

Return to Provider Information index page.