TENNCARE LONG-TERM SERVICES AND SUPPORTS CHOICES HOME AND COMMUNITY BASED PROVIDER APPLICATION. Provider Name:

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1 TENNCARE LONG-TERM SERVICES AND SUPPORTS CHOICES HOME AND COMMUNITY BASED PROVIDER APPLICATION Provider Name: Corporate Name: (as on W9) DBA Name: (if applicable) Provider Type (as listed on License): Please check all that apply. Assisted Care Living Facility: Adult Day Care: In-Patient Respite: Home Delivered Meals: In-Home Respite: Attendant Care: Personal Care: Assistive Technology: Minor Home Modification: Personal Emergency Response System (PERS):

2 Pest Control: Community Living Supports - Residential Habilitation: provided by above (grey box) facility Community Living Supports - Supportive Living: provided by above (grey box) facility Community Living Supports - Family Model: provided by above (grey box) facility **All Subcontractor Agreements must be pre-approved by UnitedHealthcare LTSS CHOICES Provider Network. This form does not constitute written approval of a subcontractor.** Primary Physical Street PO Box (if applicable): City: State: Zip Code: Phone: Fax: Contact Name: Title: Mailing (if different from Primary Address above) Street PO Box (if applicable): City: State: Zip Code: Phone: Fax: Contact Name: Title:

3 Remit (if different from Primary Address above) Street PO Box (if applicable): City: State: Zip Code: Phone: Fax: Contact Name: Title: Federal Tax ID Number (TIN): Is this Tax ID used for all locations? Yes No (If no, please contact UnitedHealthcare CHOICES HCBS Network Management at for further instruction) Medicaid Certified: Yes No National Provider Identification (NPI) Number: (if applicable) TennCare HCBS Medicaid ID Number: MINORITY BUSINESS (Complete this section if applicable. TennCare required reporting) Minority Business: Yes No Certified: Yes No If Minority Business, Check which response applies: African American Hispanic American Asian American Native American American Woman

4 MULTIPLE LOCATIONS (Complete this section if you have more than one location operating under the same Tax ID Number. If separate TAX ID Number, please complete a separate application)

5 Please check each county you provide service in. If services are not the same in all counties, please specify below in the comments section. Middle TN Counties East TN Counties West TN Counties Bedford Maury Anderson Knox Benton Cannon Montgomery Bledsoe Loudon Carroll Cheatham Moore Blount Marion Chester Clay Overton Bradley McMinn Crockett Coffee Perry Campbell Meigs Decatur Cumberland Pickett Carter Monroe Dyer Davidson Putnam Claiborne Morgan Fayette DeKalb Robertson Cocke Polk Gibson Dickson Rutherford Franklin Rhea Hardeman Fentress Smith Grainger Roane Hardin Giles Stewart Greene Scott Haywood Hickman Sumner Grundy Sequatchie Henderson Houston Trousdale Hamblen Sevier Henry Humphreys VanBuren Hamilton Sullivan Lake Jackson Warren Hancock Unicoi Lauderdale Lawrence Wayne Hawkins Union Madison Lewis White Jefferson Washington McNairy Lincoln Williamson Johnson Obion Macon Wilson Shelby Marshall Tipton Weakley If you need to provide additional detail to service counties, please use space below or attach sheet Comments:

6 I attest that the information supplied on the application for participation with UnitedHealthcare in the TennCare LTSS CHOICES program is accurate and does not misrepresent the entity. Signature: Printed Name: Title: Date: ADDITIONAL REQUIRED DOCUMENTS: (please submit with application) W9 Disclosure of Ownership Proof of Liability Insurance Copy of appropriate license: o PSSA for In Home Services o ADC for Adult Day Care o ACLF for Assisted Care Living Facility o Charter for Pest Control o Business License for Assistive Technology & Home Delivered Meals o Contractor License for Minor Home Modifications o Community Living Supports - for Residential Habilitation, Supportive Living, or Family Model RETURN APPLICATION & DOCUMENTS: Fax #: ATTN: Jennifer Perry ( [email protected])