An Important Message to Massachusetts Families with ...



Re-Certification of Credentials for Individual Providers

I, (Print Name) , certify that the statements made on my Autism Waiver Program Individual Provider Application remain true and complete to the best of my knowledge. I attest to not having any professional disciplinary actions against me since becoming a provider of Autism Waiver Services. I also certify that there is no change in my National Background Check or CORI status as it relates to my ability to legally provide services to children.

I understand that if I knowingly make any misstatements of fact that I am subject to disqualification and dismissal and to such other penalties as may be prescribed by law or personnel regulations.

I understand that all statements made on this application, including credentials and therapist licensure requirements are subject to verification as a condition of employment. By signing this statement, I hereby give permission for the staff of the Autism Division to request and review materials as necessary for the services provided to individuals enrolled in the Autism Waiver Program.

Signature of Provider: ____________________________________Date:_________

Please return completed form via Postal Mail, fax or e-mail to an Autism Support Broker at your local Autism Support Center or e-mail directly to PPLMA_Autism@

*Due: One year from original application date or last re-certification*

Listing of the Autism Support Centers:

HMEA: Autism Resource Central

712 Plantation St, Worcester, MA 01605 #508-835-4278: Serving Central, MA

Pathlight: Autism Connections

116 Pleasant St. Easthampton, MA 01027 #413-529-2428: Serving Western, MA

Community Autism Resources (CAR)

33 James Reynolds Rd, Unit C, Swansea, MA 02777 #508-379-0371: Serving Southeastern, MA

TILL, Inc.: Autism Support Center

20 Eastbrook Rd. Dedham, MA 02026 #781-302-4600 x 4661: Serving Greater Boston

SNCARC: The Family Autism Center

789 Clapboardtree Street, Westwood, MA 02090 #781-762-4001, X. 395: Serving Norfolk County Area

NEARC: The Autism Support Center

6 Southside Road, Danvers, MA 01923 #978-777-9135: Serving Northeastern, MA

Advocates: Autism Alliance of MetroWest (AAMW)

1881 Worcester Rd, Framingham, MA 01701 #508-652-9900: Serving Metro West of Boston

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