The code block below illustrates how one might use # and // as comments in your logic and calculations.

This value you provided is not a number. Please try again.

This value you provided is not an integer. Please try again.

The value entered is not a valid Vanderbilt Medical Record Number (i.e. 4- to 9-digit number, excluding leading zeros). Please try again.

The value you provided must be within the suggested range

The value you provided is outside the suggested range

This value is admissible, but you may wish to double check it.

The value entered must be a time value in the following format HH:MM within the range 00:00-23:59 (e.g., 04:32 or 23:19).

This field must be a 5 or 9 digit U.S. ZIP Code (like 94043). Please re-enter it now.

This field must be a 10 digit U.S. phone number (like 415 555 1212). Please re-enter it now.

This field must be a valid email address (like joe@user.com). Please re-enter it now.

The value you provided could not be validated because it does not follow the expected format. Please try again.

Required format:

sUnuuQHKDspDkLdxvMaWRSNxUxwkex3LbVZokoMJPjQA3HbnKGWrytQpSH7ZLH64NvMgAchRax

Provider Notice Portal

Returning?

A A A

This portal is for Division of DD contracted providers to give the Division of DD notice of its intent to terminate community services to an individual under their care. Use of this portal satisfies notice requirements under the Division of DD Purchase of Services contract, section 3.3.5 requiring a thirty (30) day notice or section 3.3.4 requiring a ten (10) calendar day notice. This portal is not intended to provide notice to the individual’s support coordinator, the individual, or the individual’s guardian. Providers will have to attest that they have already provided notice to these parties through separate mechanisms.

Provider Name

* must provide value

Contact Name

* must provide value

Contact Phone Number

Contact Email

* must provide value

What type of services are you giving notice for?

* must provide value

ISL

Group Home

Shared Living

Non Residential (Day Habilitation, Employment, etc.)

Both ISL and Non Residential

Both Group Home and Non Residential

Both Shared Living and Non Residential

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What non residential service(s)? (Check all that apply)

* must provide value

Behavior Analysis Services

Community Networking

Community Specialist

Day Hab

DME/SME

Employment

Environmental Accessibility Adaptations

Home Delivered Meals

Individual Skills Development

OT/PT/ST

Peer Support

Personal Assistance

Professional Assessment and Monitoring (PAMs)

Remote Supports

Respite

Support Broker

Transportation

Other

Individual's Name

* must provide value

Individual DMH ID

* must provide value

Regional Office

* must provide value

TCM Name

* must provide value

Support Coordinator

* must provide value

Support Coordinator Email

* must provide value

Reason for Providing 30 Day or 10 Day Notice
*Check all that apply

* must provide value

Capacity/Staffing Issues

Behavioral Support Needs of Individual

Medical Support Needs of Individual

Contract Ending with DMH

Other

Description of Reason for 30 Day or 10 Day Notice

* must provide value

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Provider's total number of vacant beds at time of notice.

* must provide value

Are you interested in discussing with the Regional Office and/or Support Coordinator additional resources to continue providing care to this individual?

* must provide value

Yes No

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Who would you like to communicate with?

What information or resources are you wanting to discuss to continue to support this individual?

Any Additional Information to provide?

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I have provided notice of my intent to terminate services to the individual's support coordinator.

* must provide value

Add signature

I have provided written notice of my intent to terminate services to the individual or his/her guardian.

* must provide value

Add signature

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