A. Rehabilitative Services for Youth performing providers must complete a provider application (Form DMS-652), a Medicaid contract (Form DMS-653) and a Request for Taxpayer Identification Number and Certification (Form W-9) with the Arkansas Medicaid Program. (View or print a provider application (Form DMS-652), Medicaid contract (Form DMS-653) and Request for Taxpayer Identification Number and Certification (Form W-9).

B. The performing provider must be certified by the Division of Youth Services as having programs and professional staff capable of delivering the rehabilitative services offered under the Arkansas State Plan. A copy of the applicant's certification must accompany the provider application and the Medicaid contract. Subsequent certification renewals must be provided for continuous enrollment.

C. The provider application and the Medicaid contract must both be approved by the Arkansas Medicaid Program.