Purpose:
To collect provider level information that will:
1. Inform DHS/ODP about risk/service closures and guide decision making
2. Create a record if Appendix K is implemented for the purposes of retroactive approvals, documentation and payment
Providers, please complete this Information Tool as many times as needed to provide updates and changes.
Instructions: Please have all information ready to enter prior to beginning the survey. If left idle for too long, the survey will time out. After entering all information you will see a screen to review/print. An email will also be sent. Please save a copy and maintain in files.
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