Become A Qualified Vendor

1.    Check that you meet these requirements for Qualified Vendors:

• Be a for-profit corporation, non-profit corporation, limited liability company, or limited liability partnership.
• Have an employer identification number from the Internal Revenue Service (IRS).
• Be registered with the Arizona Corporation Commission to conduct business in the State of Arizona.
• Have insurance coverage, including limits and endorsements, as stated in the contract award.
• Have an established internal system to ensure compliance with requirements for providers, employees, and contractors. This includes performing employee background checks, certification, service delivery, documentation, and billing for services.

2.    You will need to submit the following information to complete the Qualified Vendor application:

• The information stated above
• Telephone number for agency
• Email address for agency
• Name of Administrator/owner of agency
• Listing of staff for the various services you plan to offer
• Program Management description (Vendor Policies)
• Business Address for Administration Site and email and telephone numbers, including the staff who will be listed as the primary contact, scheduler and after-hours contact
• Name of Service(s) and their description(s) (you will need service information for 21 different sections in the description portion of each service)
• Business Plan document
• Business Contingency Plan
• Financial information for the last three years or prior year’s audit of the agency you currently own or operate

3.    Vendors need to apply for and submit their Federal Employment Identify Number (FEIN).

4.    A vendor or an individual that is to receive payment electronically (e.g., direct deposit) from the Department of Economic Security Division of Developmental Disabilities must set-up a vendor account with the Arizona Department of Administration General Accounting Office (ADOA-GAO). Vendors who are sole proprietors and have no employees must complete and submit a Sole Proprietor Waiver form. By completing, signing and submitting this form, you waive your rights to workers’ Compensation coverage and benefits. NOTE: to be processed, your completed form must identify “Arizona Department of Economic Security” as the State Agency and list “220” as the Agency number.

5.    Any vendor that provides goods or services to an Arizona state agency and receives payment from the State of Arizona must complete the Arizona W9 form. Use the Arizona W9 form to establish or update a vendor account with the State of Arizona.  The Arizona W9 form is a substitute for the Federal form W-9 and it fulfills the Federal requirement to provide a Taxpayer Identification Number (TIN) and information concerning Federal income tax withholding.

6.    Prior to, or during the application process, you will be required to:

• Be registered as a provider with the Arizona Health Care Cost Containment System Administration (AHCCCS) and become certified as a Home and Community Based Services (HCBS) provider with the DES/DDD Office of Licensing, Certification, and Regulation (OLCR).
• Obtain a National Provider Identifier (NPI) and submit your NPI to AHCCCS (for Qualified Vendors that provide nursing and/or occupational, physical, or speech therapy services). This requirement also applies to individual practitioners who deliver services on behalf of a Qualified Vendor.