STEPS TO BECOMING A CERTIFIED WAIVER PROVIDER
Ohio Dept of Developmental Disabilities: http://odmrdd.state.oh.us/providers/new.htm
Info link to NEON about becoming an independent provider and required training
For assistance with the application forms and the process, plan to attend Precertification class.
• Be at least 18 years of age
• Hold a high school diploma or GED (Note: Currently certified independent providers and currently engaged
direct services employees of certified agency providers are exempted from this requirement.)
• Have a Social Security card and valid identification
• Have a Bureau of Criminal Identification and Investigation (BCII) report
• Not be on the Abuser Registry
• Not be on the Nurse Aide Registry indicating the Ohio Department of Health has made a determination of
abuse, neglect, or misappropriation of property of a resident of a long-term care facility or residential care
• Be able to read, write, and understand English at a level sufficient to comply with rules governing the
• Be able to effectively communicate with the individual served
• Hold valid First Aid certification
• Hold valid CPR certification
• Have completed eight hours of training in: Serving individuals with developmental disabilities,
Individual rights, Providing HCBS waiver services, Requirements of rule 5123:2-17-02 (Incidents
Adversely Affecting Health and Safety) and Universal Precautions for infection control
The 8 hour training is available for free:
Training Classes are also available for a fee on line at:
Evidence of First Aid and CPR training is required. Training is available through:
American Red Cross: http://www.redcross-cleveland.org/training/
American Heart Association: www.americanheart.org
CPR Ohio: www.cprohio.com.
Shull Medical Educators:
CPR 1st aid Shull
Required application forms:
Form # Description
ODJFS-6750 Ohio Health Plan Provider Application/Agreement for Individual Practitioners
OBM-5657 OBM Vendor Information Form
Form W-9 Taxpayer Identification Form
HLS-0038 Request form for the denial of funding or business contract
Terrorist Exclusion List
Most Commonly Requested Service Applications
-This is a list of the most commonly requested services. For the complete list of services, go to
CERT01 Provider Certification Application
CERT-02 Homemaker/Personal Care, Independent/Agency Provider
CERT-03 Transportation, Independent/Agency Provider
CERT-04 Transportation Mileage Other Than to Access Adult Day Services,
BCII criminal background check is required. List of BCII locations is attached:
Please ask them to have the results sent to your address and include the results with application
ODMRDD Certification Unit phone is 1-877-289-3636 for questions about the application. If help is
needed with the application and process, plan to attend Precertification class, which is offered monthly.
Go to the NEON website for the schedule of classes.
Mail application forms, application fee (Money Order or Check), evidence of training, BCII
background check results, copy of Social Security card, copy of High school diploma or GED,
copy of driver's license, and auto insurance (if applying to provide transportation services) to:
OHIO DEPARTMENT OF MR/DD
PROVIDER CERTIFICATION UNIT
30 E. Broad Street, 13th Floor
Columbus, Ohio 43215-3434
Make a copy of everything before mailing.
Upon certification, fax the Initial and Final approval letters to 216-736-4547. Plan to attend New Provider
Orientation class to learn about the required documentation and billing process. Go to the NEON website
for the schedule of training classes.
Questions, please call the Provider Inquiry Line at 216-556-0062 and someone will return your call.
Revised by Aggie Girt, 7/15/10