Application for New Service Providers
Submit the following information to jpolley@transformationsllc.net.
1) Resume
2) Administrative Office of the Courts Criminal Records Report
a. On line go to http://courts.ky.gov/aoc/criminalrecordreports/Pages/default.aspx
b. Click on Background Check and then on One Time Request
c. Click on New User Registration, then submit record request.
d. Pay by credit or debit card ($25.00 fee).
3) Complete the Cabinet for Families and Children form for a record check. To download the form Central Registry Check click here. Copy the form to a photo or jpeg or pdf form and mail to jpolley@transformationsllc.net. Do your background checks first as the results may take up to 30 days.
4) Certificate of Professional liability insurance: Kentucky Medicaid requires a minimum coverage of “one million dollars per occurrence and 3 million dollars aggregate”. This must be “occurrence” insurance. Additionally Insured is required for all contractors. Transformations Hope for Today’s Families, LLC 4010 Dupont Circle Suite 582 Louisville KY 40207 must also be named on to your policy as an Additionally Insured. If you will be providing services in Jefferson County Public Schools, JCPS also requireds that they be listed on your certificate as an Additionally Insured :We recommend CPH and Associates for insurance coverage.
5) Proof of Professional License with expiration date. If you do not have a license, send a copy of your transcripts. This does not need to be an official copy. If you have an associate license, also send copies of your supervision agreement along with the name and contact information for the supervisor.
6) Driver’s License.
7) Social Security card
8) IRS letter documenting your Federal Employer Identification Number (FEIN),if you have one.
9)NPI number and taxonomy code report from NPPES: https://nppes.cms.hhs.gov/NPPES/Welcome.do
10) Automobile Insurance Policy stating that you are “Covered For Business Purposes”. Transporting clients is not required.
11) Statement-of-Disclosure. Review and sign.
12) State Regulations Agreement: You must read and document agreement to follow all state regulations governing the services provided by Transformations. Click here to access and read the state regulations. Then Click here to sign the signature page.
13) References: Complete three releases for references along with their contact information. Click here for the Reference form.
14)Persons listed on the Kentucky Medicaid Provider Termination and Exclusion List are not eligible for contract or employment with Transformations