PAA#7 REQUEST FOR PASSPORT AGREEMENT RENEWAL/EXPANSION

Purpose of Request (check all that apply)

0 Renew provider agreement-same service 0 Expand into another PAA. Note: Must be certified in another PAA.

0 Add or delete services (circle which) Certified in PAA _________________________________________

0 Change counties served (same PAA) DATE OF REQUEST:

PROVIDER
NAME:
DOING BUSINESS AS:
OWNERSHIP TYPE:	(circle) Private Charitable/Religious Public/govt Private/Non profit Other	MEDICARE NUMBER:
LEGAL STRUCTURE:	(circle) Corporation Non-profit corp Partnership S-Corp Sole Proprietorship Vol Corp	GROUP SIZE:
GROUP TYPE:	(circle) Corporation Group Medical Practice HMO Other Partnership	GROUP NUMBER:
TYPE:	(circle) PASSPORT Home Health Agency Phys Therapy Pharmacy Home Medical Supplier	FED ID/SSN:

	CORPORATE	BUSINESS	MAILING
IN CARE OF:
ADDRESS:
CITY/STATE/ZIP:
PHONE:
FAX:
EMAIL:
CHANGE IN OWNERSHIP? 0YES 0NO If “yes,” please attach a separate statement
CHANGE IN governing body? 0YES 0NO If “yes,” please attach a separate statement
CHANGE IN management or administration? 0YES 0NO If “yes,” please attach a separate statement

Person authorized to sign provider agreement
Name:	Address:
Title:	Phone:	Fax:

Form completed by:___________________________________________________ title:__________________________________ Date:______________

PAA#7 REQUEST FOR PASSPORT RENEWAL/EXPANSION

Please check current and new services you wish to provide.	Service		COUNTIES	RATE	CURRENT RATE	PAA use only
	Current	New
¡ Adult Day Care - Enhanced				$40/day		$40/day
				$20/ ½ day		$20/ ½ day
				$1.25/ 15 min. unit		$1.25/ 15 min. unit
¡ Adult Day Care - INTENSIVE				$40/day		$40/day
				$20/ ½ day		$20/ ½ day
				$1.25/ 15 min. unit		$1.25/ 15 min. unit
¡ ADS Transportation				UP TO $1.44/MILE		UP TO $1.44/MILE
				$15.08/ONE WAY		$15.08/ONE WAY
				$19.40/ROUND TRIP		$19.40/ROUND TRIP
¡ Home Delivered Meals ¡ Hot ¡ Frozen				/meal /meal		/meal /meal
¡ HDM -SPECIAL ¡ Hot ¡ Frozen				/meal /meal		/meal /meal
¡ Homemaker				/hour		/hour
¡ ILA ¡ IN-PERSON ACTIVITIES ¡ TELEPHONE SUPPORT ¡ TRAVEL ATTENDANT				/hour /call /hour		/hour /call /hour
¡ Nutrition Consultation				/hour		/hour
¡ Personal Care/Respite				/hour		/hour
¡ Social Work/Counseling				/hour		/hour
¡ Occupational Therapy				$70/day		$70/day $4.50/ 15 min unit
				$4.50/ 15 min unit
¡ Physical Therapy				$70/day $4.50/ 15 min unit