Credentialing Attestation for Adult Day Care Centers Providing Enhanced Services

  • State of Rhode Island Provider Certification Standards Adult Day Care

    Neighborhood Health Plan of Rhode Island’s (Neighborhood’s) participating Adult Day Health Providers should refer to the State of Rhode Island’s Certification Standards for detailed requirements to provide Enhanced Level of Services. A copy of that documentation can be found above.

    Directions:
    1. A facility must already be credentialed in Neighborhood’s network.
    2. List facility’s Legal name and NPI in boxes provided below.
    3. An authorized individual of the facility must attest that the following criteria are met by placing their initials adjacent to each criterion.
    4. Same authorized individual signs / dates attestation with their title.
  • Please attest to the below information by providing your initials in the box provided below.

  • Affirmation: Please Initial
  • Affirmation: Please Initial
  • Affirmation: Please Initial
  • Affirmation: Please Initial
  • Affirmation: Please Initial
  • Affirmation: Please Initial
  • MM slash DD slash YYYY
  • MM slash DD slash YYYY
  • Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.