Service Providers

The Waiver is in need of people interested in becoming service providers.   Having providers available to serve children/youth and families is the key to implementing the program. 

Waiver service providers are persons or agencies (public or private) that meet qualification and certification requirements established by the Waiver Program. Providers must also be enrolled as a Medicaid service provider. 

• Any willing and qualified provider (per Medicaid requirements) who meets the Waiver Program's provider certification requirements (approved by CMS). This is determined through completion of an application process.
• Must successfully pass criminal history/background investigation as well as abuse registry screening.
• Must complete initial waiver certification training and attend ongoing continuing education opportunities provided on a quarterly schedule.

CLICK HERE to review provider qualifications. 

CLICK HERE to review the roles of the different waiver providers.

 

Service providers are chosen by the child/family and are authorized to provide specific services as outlined in an individualized plan of care.

CLICK HERE to view Active Children's Mental Health Waiver Providers. 

CLICK HERE to see how waiver providers make their money. 

 

How To Become a Waiver Provider

Waiver Provider Enrollment Instructions

1. Initial Provider Certification Process- Please Read this first

2. Background Check Information

3. Provider Background Submission Review form

4. Fingerprint and Screening Nontransferable statement

5. Instructions for Adult Central Registry Screens

6.  Application for Child Abuse/Neglect and Adult Central Registry Screens and Wyoming Criminal History and Wyoming Crminal History Record Prescreens

7. Waiver Provider Application Form

8. Employment History

9. Provider Information Form

10. Provider Confidentiality Statement 

11. Provider Reminder Information List

Medicaid Provider Enrollment Forms

1.EqualityCare (Wyoming Medicaid) Provider Enrollment Application

2.EqualityCare (Wyoming Medicaid) EDI Application and Trading Partner Agreement

Waiver Provider Program Forms

Family and Child Trainer Services Checklist

Family Care Coordinator ISP Checklist

Family Care Coordinator Services Checklist

Family Care Coodinator Services Checklist

Documents Directory

FCC 1 FCT Family Care Team Monthly Service Plan Review

FCC 2 Individual Service Plan Modification

FCC 3 Pre-Approval for Modification to Children's Mental Health Waiver Service Plan

FCC 4 Family Assessment

FCC 5 Youth Health/Safety Review

FCC 6 Psychotropic Medication Consent Form

FCC 7 Individual Service Plan/Budget Worksheet

FCC 8 ISP Budget Worksheet

FCC 9 Team Meeting Minutes

FCC 10 Discharge Plan

FCC 11 Out of Home Care Status Report

FCC 12 Child and Family Training- Children

FCC 13 Child and Family Training- Pre-teen

FCC 14 Child and Family Training- Young Adult

FCC 15 Document of Training

FCC 16 ISP Review Criteria for Plan Approval

FCT 1 ISP Waiver Service Objective

FCT 3 Progress Notes

FCT 5 Family Care Team Member Assessment Report

FCT 6 ISP Behavior Support Plan

Information to Develop a Behavior Support Plan

Letter to Prescribing Clinician

Provider Transition Checklist

Psychiatric Medications for Children and Adolescents Questions for Parents to Ask

Suggestion Box Form

Waiver Service Plan Team Meeting Agenda

WA 8 Provider Information Form

WA 10 Notice of Conviction Form

WA 11 Provider Continuing Education Tracking Record

WA 13 Recertification Checklist

WM 4 Notice of Incident

WM 5 Complaint Form

WP 1 Individual Service Plan/Budget

WP 3 Level of Care Criteria Re-Evaluation

WP 4 Exceptional Service Plan Request

WP 9 Freedom of Choice Statement

WP 10 Choice of Providers Form