Regulation .06 Conditions for Provider Participation.

Name, address, and telephone number of the participant;

Medical Assistance number of the participant;

Name and telephone number of the participant’s primary care provider and of any managed care organization with which the participant is enrolled;

Dated signatures of the participant or authorized representative, and each of the other individuals participating on the multidisciplinary team;

A statement that the participant or authorized representative shall have access to the individual's medical day care services plan of care;

A statement that enrollment is voluntary, but that the participant or the participant's caregiver shall notify the medical day care center when the participant is unable to attend;

Authorization and frequency of attendance of medical day care services;

Names of provider or providers that render waiver or State Plan services; and

Approval by the Department or its designee.