Provider Enrollment

The Adult Services Division is responsible for approving all new providers of the Choices for Care (home-based, Adult Family Care, Enhanced Residential Care) and Traumatic Brain Injury programs. This page provides an overview of the provider enrollment process by provider type and provider-specific fillable enrollment applications.

Instructions:

1. Before applying as a Choices for Care or Traumatic Brain Injury Provider read this: "Provider Enrollment Process Summary"

2. When you are ready to submit an application, click on the fillable application below, save a copy and fill in the form.

3. Follow all instructions for required attachments and send the form to the email on the application form. AHS.DAILASDProviderEnrollment@vermont.gov.

4. If approved by DAIL, the provider will then be instructed to submit a Medicaid Provider Enrollment application with the State's Medicaid Fiscal Agent.

Non-Fillable Application Form:

• Out of State Nursing Facility Choices for Care Provider Enrollment Application

Fillable Application Forms:

• Adult Day Provider Enrolllment Application

• Adult Family Care (AFC) Authorized Agency Provider Enrollment Application

• Enhanced Residential Care Provider Enrollment Application

• Home Care Provider Application

• Personal Emergency Response Provider Enrollment Application

• Traumatic Brain Injury Provider Enrollment Application

Additional Instructions:

• Assistive Community Care Services (ACCS) Enrollment Procedures
• ERC Program Provider Application Procedures