Indiana First Steps Application for Enrollment & Personnel Info
The Indiana First Steps Application for Enrollment & Personnel Information Form is required for providers to enroll in First Steps program. This form includes sections on personal information, billing details, attestation, and supervision agreement. Ensure to provide all the necessary documentation to expedite the enrollment process.
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How do I fill this out?
To fill out the Indiana First Steps Application for Enrollment & Personnel Information Form, start by downloading the form. Carefully fill in all the required fields with accurate information. Make sure to attach all necessary documents as listed in the enrollment checklist.
How to fill out the Indiana First Steps Application for Enrollment & Personnel Info?
1
Download the Indiana First Steps Application for Enrollment & Personnel Information Form.
2
Carefully fill in all required fields with accurate information.
3
Attach all necessary documents as listed in the enrollment checklist.
4
Sign the attestation statement and supervision agreement (if applicable).
5
Submit the completed form and supporting documents to the specified address.
Who needs the Indiana First Steps Application for Enrollment & Personnel Info?
1
Audiologists need this form to enroll as independent providers in the First Steps program.
2
Interpreters are required to use this form for their enrollment in the program.
3
Physicians will need to complete this form to be authorized as providers under the First Steps program.
4
Psychologists must fill out this form to become enrolled providers.
5
Registered dietitians who wish to provide services under First Steps need this form.
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Use the PDF editor to fill in required fields with accurate information.
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Attach necessary supporting documents using the upload feature.
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What are the instructions for submitting this form?
Submit the completed Indiana First Steps Application for Enrollment & Personnel Information Form along with the required supporting documents to the First Steps Central Reimbursement Office (CRO). You can email the documents to infsenroll@dxc.com, fax them to 913-888-6683, or mail them to Indiana First Steps Provider Enrollment, c/o CSC, P.O. Box 29160, Shawnee Mission, KS 66201-9160. Ensure all details are accurate to expedite the enrollment process.
What are the important dates for this form in 2024 and 2025?
Ensure to keep up with enrollment deadlines and document submissions for 2024 and 2025 to maintain your eligibility as a provider in the First Steps program.
What is the purpose of this form?
The purpose of the Indiana First Steps Application for Enrollment & Personnel Information Form is to facilitate the enrollment of qualified professionals into the First Steps program. This program aims to provide essential services to eligible children with developmental delays or disabilities. By completing this form, providers ensure they meet all the requirements and are authorized to offer their specialized services.
Tell me about this form and its components and fields line-by-line.
- 1. Enrollment checklist: Contains a list of required documents and tasks to complete the enrollment.
- 2. Form Type: Indicates whether the form is for new enrollment or a change of information.
- 3. Enrollment Type: Specifies the type of enrollment such as Dual, With SPOE, With provider agency, or Independently.
- 4. Prior Convictions: Asks if the provider has been convicted of a crime other than a minor traffic violation.
- 5. Personnel Information: Gathers personal details, professional credentials, and contact information.
- 6. Billing Information: Collects billing details for providers enrolling with an SPOE or provider agency.
- 7. Independent Provider Billing Information: Required if billing information is different from the Personnel Information section.
- 8. Supervision Agreement: Section for supervised providers to have their supervising provider sign and provide credentials.
- 9. Attestation Statement: Provider's declaration that they meet the requirements for offering First Steps services.
What happens if I fail to submit this form?
Failure to submit the completed form may result in delays or disqualification from the First Steps program.
- Delayed Enrollment: Without the form, the enrollment process cannot be completed, causing delays.
- Disqualification: Providers may be disqualified from offering services under the First Steps program.
How do I know when to use this form?
- 1. New Enrollment: For providers who are enrolling in the program for the first time.
- 2. Change of Information: For existing providers who need to update their personal or professional details.
- 3. Additional Enrollment: For providers enrolling with more than one agency or SPOE.
Frequently Asked Question
What is the purpose of the Indiana First Steps Enrollment Form?
The form is used to enroll providers in the Indiana First Steps program, ensuring they meet necessary requirements and provide relevant services.
Can I edit the Indiana First Steps Enrollment Form on PrintFriendly?
Yes, you can use our PDF editor to make changes directly on the form.
How can I attach additional documents to the form?
Use the upload feature in PrintFriendly's PDF editor to attach necessary supporting documents.
How do I sign the form on PrintFriendly?
Utilize the digital signature feature to sign the form without printing it.
Can I share the completed form via email?
Yes, after completing the form on PrintFriendly, you can share it via email directly from our platform.
What should I do if I have multiple provider agencies?
If enrolling with multiple agencies, complete page 3 for each agency/SPOE.
Is there a checklist for independent providers?
Yes, refer to the additional checklist for independent providers included in the form.
What should I do if I change my information?
Mark 'Change of information' and provide updated details in the Personnel Information section.
How can I fill out the Billing Information section?
Complete the Billing Information section if enrolling with a SPOE or provider agency.
How do I submit the completed form?
Submit the form via email, fax, or mail to the provided CRO address.
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