STATE OF CONNECTICUT
STATE OF CONNECTICUT
DEPARTMENT OF SOCIAL SERVICES
25 SIGOURNEY STREET • HARTFORD, CONNECTICUT 06106-5033
Provider Agreement
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|Date: ________________ |
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|Agreement between the Connecticut Department of Social Services (DSS) and |
|Provider _____________________________________ |
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|G. Address |
|_____________________________________________________________________ |
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|Phone _________________________________ Fax ______________________ |
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|The provider agrees to accept check(s) for item(s) or service(s) purchased for individuals served through the DDS Individual and |
|Family Support Waiver or the DDS Comprehensive Waiver. Financial management, for these purchases, is provided by DDS contracted |
|fiscal intermediaries, which is not a Connecticut government agency. Acceptance and endorsement of the check(s) will signify that |
|the provider agrees to the following terms and conditions: |
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|a. Accept payment, in form of check(s), from DDS contracted fiscal intermediaries doing |
|business in Connecticut. |
|b. Agree to keep records of the service(s) or purchase(s). |
|c. Provide only the service(s) or item(s) authorized on the check(s). |
|d. Accept the check(s) as payment in full for the service(s) or item(s) purchased. |
|e. No additional charges will be made or accepted from clients. |
|f. Upon request, provide DSS or its designee information regarding the service(s) or purchase(s) for which payment was made. |
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|_______________________________ ____________________________ |
|DSS Representative Provider Representative |
An Equal Opportunity / Affirmative Action Employer
Printed on Recycled or Recovered Paper
Appendix R 10/13/2005
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