Thank you for your interest in becoming a provider of CHOICE, SSBG, Title III funded services. The steps below outline the process and requirements  for becoming a provider. If there are questions regarding this information, you may contact Emily Arent, Provider Coordinator, at 317-803-6044 or This e-mail address is being protected from spambots. You need JavaScript enabled to view it .

Effective January 9, 2012, CICOA Aging & In-Home Solutions is not accepting provider enrollment applications from Personal Service Agencies that primarily staff Marion County. Personal Service Agencies who are actively serving clients in the following outlying counties are welcome to apply: Boone, Hancock, Hendricks, Morgan, and Shelby. Provider enrollment for other services remains open at this time.

APPLICATION PROCESS FOR IN-HOME SERVICES

1. Providers must be approved by the Indiana Medicaid Waiver Unit as Medicaid Waiver Providers for applicable services and return a copy of the certification letter with the application packet. To access a copy of the Medicaid Waiver application packet, please contact Linda Wolcott, Indiana Division of Aging, at 317-234-0373.
2. Providers must comply with all applicable Indiana State Department of Health (ISDH) licensing standards required to deliver requisite services and include current license with packet.
3. After a provider has completed the process for Medicaid Waiver certification and has secured licensure through the Indiana State Department of Health, it may then submit an application to provide CHOICE, Social Service Block Grant (SSBG) and Title III services through CICOA.
4. The provider will submit to CICOA the completed Provider Profile and a Certificate of Insurance (COI) verifying:
   • General aggregate liability insurance in the minimum amount of $1,000,000, with CICOA Aging & In-Home Solutions listed as additional insured.
   • Workers’ compensation insurance as required by the State of Indiana, with CICOA Aging & In-Home Solutions listed as certificate holder.
5. Providers will be notified by CICOA within two weeks of receipt of provider application packet. Provider Coordinator will be in contact with in-home service providers to schedule a pre-site visit.
6. After the pre-site visit is completed, the decision to enroll will be rendered by the Provider Coordinator. If approved, the Provider Coordinator will forward the contract to the President/Executive Director of providing agency for review and signature.
7. Contract should be signed by President/Executive Director of providing agency and returned to CICOA within two weeks. Upon receipt, CICOA’s Executive Director will sign the contract and provider will receive an emailed copy of the executed agreement.
8. Providers should be aware that the establishment of a contractual agreement provides no guarantee of referrals for service to the agency.
9. Providers currently must be serving at least one client (private pay or Medicaid waiver) in order to be considered for enrollment.

Please submit the following documents to begin the application process to become a CHOICE/SSBG/Title III provider:

• Provider Profile
• Form W-9
• Certificate of Insurance for general aggregate liability coverage of at least $1,000,000, with CICOA Aging & In-Home Solutions listed as additional insured
• Certificate of Insurance for worker’s compensation insurance, with CICOA Aging & In-Home Solutions listed as certificate holder
• Current license
• Medicaid waiver provider certification letter

Documents can be submitted via email, fax or mail to:

• Email: This e-mail address is being protected from spambots. You need JavaScript enabled to view it
• Fax: 317-803-6044
• Mail:
  CICOA Aging & In-Home Solutions
  Attention: Emily Arent
  4755 Kingsway Drive, Suite 200
  Indianapolis, IN 46205