"New Provider Orientation Acknowledgement Form" - Tennessee

This "New Provider Orientation Acknowledgement Form" is a document issued by the Tennessee Department of Intellectual and Developmental Disabilities specifically for Tennessee residents with its latest version released on July 18, 2018.

Download the up-to-date fillable PDF by clicking the link below or find it on the forms website of the Tennessee Department of Intellectual and Developmental Disabilities.

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Download "New Provider Orientation Acknowledgement Form" - Tennessee

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New Provider Orientation
Acknowledgement Form
The Department of Intellectual and Developmental Disabilities (DIDD) Provider Manual Chapter 5.8
states the following positions, listed below, “are required to attend a DIDD New Provider Orientation
within ninety (90) calendar days of being appointed/assuming office or beginning contracted services with
DIDD- or complete the online equivalent”:
5.8.a.8: Not for Profit: Board Chairperson and Chief Executive Officer/Executive Director
5.8.b.5: For Profit: Executive Director
By my signature, I certify:
1.
I have chosen to review the online New Provider Orientation materials in lieu of attending the New Provider
Orientation class;
2.
I have reviewed and familiarized myself with the New Provider Orientation materials regarding the policies,
philosophies, practices, benefits, and expectations of the Department of Intellectual and Developmental
Disabilities, as well as provider responsibilities;
3.
I agree to comply with the requirements specified in the New Provider Orientation materials;
4.
I understand that the New Provider Orientation Acknowledgment Form is not a contract and should not be
deemed as such;
5.
I will retain a copy of the completed New Provider Orientation Acknowledgment Form, as it must be available
for review by Quality Assurance staff during future surveys;and
6.
I will send the completed form to my Regional Office contact.
Name of Provider Agency
Date of Appointment
Printed Name and Title (board chairperson or executive director)
Signature
Today’s Date
If you choose to review the online New Provider Orientation materials prepared by DIDD in lieu of attending the New Provider
Orientation class, please review the information carefully.
Revised 07.18.2018
New Provider Orientation
Acknowledgement Form
The Department of Intellectual and Developmental Disabilities (DIDD) Provider Manual Chapter 5.8
states the following positions, listed below, “are required to attend a DIDD New Provider Orientation
within ninety (90) calendar days of being appointed/assuming office or beginning contracted services with
DIDD- or complete the online equivalent”:
5.8.a.8: Not for Profit: Board Chairperson and Chief Executive Officer/Executive Director
5.8.b.5: For Profit: Executive Director
By my signature, I certify:
1.
I have chosen to review the online New Provider Orientation materials in lieu of attending the New Provider
Orientation class;
2.
I have reviewed and familiarized myself with the New Provider Orientation materials regarding the policies,
philosophies, practices, benefits, and expectations of the Department of Intellectual and Developmental
Disabilities, as well as provider responsibilities;
3.
I agree to comply with the requirements specified in the New Provider Orientation materials;
4.
I understand that the New Provider Orientation Acknowledgment Form is not a contract and should not be
deemed as such;
5.
I will retain a copy of the completed New Provider Orientation Acknowledgment Form, as it must be available
for review by Quality Assurance staff during future surveys;and
6.
I will send the completed form to my Regional Office contact.
Name of Provider Agency
Date of Appointment
Printed Name and Title (board chairperson or executive director)
Signature
Today’s Date
If you choose to review the online New Provider Orientation materials prepared by DIDD in lieu of attending the New Provider
Orientation class, please review the information carefully.
Revised 07.18.2018
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