Application for Service Providers Submit the following information to email@example.com.
1) If you have not done so already, up-load your resume by clicking on the job title.
2) Complete the Provider Information Form and email to firstname.lastname@example.org.
2) Complete the Administrative Office of the Courts form online.
a. On line go to http://courts.ky.gov/aoc/criminalrecordreports/Pages/default.aspx
b. Click 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 email@example.com. Do your background checks first as the results may take up to 30 days.
4) Provide Proof of Professional liability insurance: You must maintain your own liability insurance. Kentucky Medicaid requires a minimum coverage of “one million dollars per occurrence and 3 million dollars aggregate”. This must be “occurrence” insurance. Transformations: Hope for Today’s Families, LLC – must also be named on your policy. Transformations is currently insured through CPH and Associates at 312-987-9823. Forward proof of insurance to Transformations at firstname.lastname@example.org
5) Provide a copy of your 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) Provide a copy of your driver’s license.
7) Copy of your social security card
8) Copy of the IRS letter documenting your Federal Employer Identification Number (FEIN),if you have one.
9) Send a copy of the email you received confirming your NPI number and taxonomy code. https://nppes.cms.hhs.gov/NPPES/Welcome.do
10) Provide proof of current automobile insurance and a copy of your insurance policy if you intend to transport clients. Your policy must indicate that you, the contractor, are covered for business purposes. Transporting clients is not required.
11) Download, sign and return the Statement-of-Disclosure. You are the applicant.
12) 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 print and sign the signature page.
13) Complete and return three releases for references along with their contact information. Click here and print three forms, complete, and return to Jenni Polley, email@example.com
14)Persons listed on the Kentucky Medicaid Provider Termination and Exclusion List are not eligible for contract or employment with Transformations
15) As of September 10, 2021 the federal government is requiring providers receiving Medicaid funding to receive the COVID-19 vaccination. Send a copy of documents showing the dates you received the vaccine to firstname.lastname@example.org. If you have decided to not receive the vaccine, you must submit documents supporting your exemption.