1. (a) Providers of health care services providing a service to a Medicaid ineligible child pursuant to a court order shall apply for certification for payment from DCYF.
2. (b) Providers of laboratory services providing a Medicaid ineligible service to a child or parent pursuant to a court order shall apply for certification for payment from DCYF.

3. (c) DCYF shall forward an application packet to the providers which includes:

   1. (1) A Form 2619 “Application for Certification of Health Care and Laboratory Service Providers”(September 2016 );
   2. (2) An “Alternate W-9 FORM –CIS (10/97)”; and
   3. (3) A copy of He-C 6348.
4. (d) Applicants shall return a signed and dated Form 2619 “Application for Certification of Health Care and Laboratory Service Providers" (September 2016) to DCYF.
5. (e) The applicant shall provide a copy of the verification of his or her state regulatory license or authorization to practice.

6. (f) The applicant’s signature on the application shall constitute an acceptance of the terms below:

   1. (1) The provider has read and understood He-C 6348; and
   2. (2) The information contained in the application is true and correct to the best of the applicant's knowledge; and
   3. (3) That all employees providing services to the child or parent are licensed and authorized to practice by the appropriate licensing entity in the provider’s state.
7. (g) The applicant shall complete and return the application within 30 calendar days to the DCYF provider relations together with the alternate W-9 and the appropriate verification.

Source. (See Revision Note at part heading for He-C 6348) #9267, eff 9-20-08; ss by #12127, eff 3-10-17