DD Waiver Provider Application

In Partnership VirginiaNavigator Family of Websites and Dept. of Behavioral Health & Developmental Services

1. AGENCY PROFILE

There are 2 parts to this application. For your first service, complete both the Agency Profile and the Service Profile. For each additional service or program you provide, fill in the Agency Name and complete a Service Profile.

CONTACT INFORMATION

Business Type

2. SERVICE PROFILE

(Examples: Dental Screening - SMILE, In-Home Physical Therapy, Outdoor Sports Program - ALLSKI)

Different Contact than Agency Profile

Complete any information in this box that is different from the contact information in the Agency Profile

General Eligibility

(Examples: Male/Female/Transgender/Family)
Languages Spoken
(List all the Cities and Counties that you serve.)
Where is the Service Provided?
(Note difference in service hours and administrative office hours, if any.)

Transportation

Do you provide transportation to/from the service?
Is this service close to Public Transportation?
We can accommodate riders with
Wheelchairs/scooters need to be dismantled for transport
To accommodate riders, we offer
Service is offered from

Cost

(Complete all options that apply)

Please check all that apply
What Funding Sources Do You Accept?

LICENSE / CERTIFICATION / ACCREDITATION INFORMATION

Does this service, program or facility require licensure, certification or accreditation to do business in Virginia?
Is this service bonded?

BUILDING AND PROGRAM ACCESSIBILITY

Creating and offering accessible and usable environments benefits everyone. This short set of questions will help older adults and people with disabilities better access your program or service.

(Answer only if service is provided to the consumer on-site)

Is there an accessible entrance to the building that has a ramp or no step or threshold over ¼ inch?
Choose all listed traits that apply to the accessible entrance
Choose all listed traits that apply to areas of your facility used by the public
Would you like to receive some information and low or no-cost tips to make your facility and programs more accessible to people with disabilities?

I understand and agree that:

The agency/service information I have provided will be included in the VirginiaNavigator database and accessible to the public at www.mylifemycommunityvirginia.org, www.VirginiaNavigator.org, www.SeniorNavigator.org, www.disAbilityNavigator.org, www.VeteransNavigator.org or additional sites as they are developed. The information is original, complete and correct. It is not pornographic, obscene, defamatory or libelous. 
VirginiaNavigator reserves the right to 1) edit information for brevity, clarity and content, 2) publish the information in a variety of media, subject to confidentiality issues, and 3) remove any submission, if they believe that information may create a liability.

DD Service Availability Survey

(If you are a Developmental Disability Service Provider, please complete the fields below.)

Indicate ALL DD Waiver services provided by your agency. (Check all that apply)
What is the number of people you support?
What is the number of people that you can currently support?
Is the program willing to expand services?
If the program is willing to expand, what is the number of people you would consider supporting?
Indicate the types of specialized supports provided by your agency. (Check all that apply)
This question is for testing whether or not you are a human visitor and to prevent automated spam submissions.