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.

Fillable Application Forms:

Contact Us

Megan Tierney-Ward, Division Director
HC 2 South, 280 State Drive
Waterbury, VT 05671-2070
Voice: (802) 241-0294
Fax: (802) 241-0385
For Telecommunications Relay Service: Dial 711

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This is a Division of the
Department of Disabilities, Aging and Independent Living
under the Agency of Human Services