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New Choices Waiver

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Attachment B Forms for New Choices Waiver Provider Enrollment


Provider enrollment applications within PRISM are frequently returned for edit because providers did not upload or complete all of the required steps. To avoid this, we strongly encourage New Choices Waiver (NCW) providers to contact the NCW Provider Specialist before submitting or validating your PRISM record to verify all of the items needed. The NCW Provider Specialist can be reached at (801)538-6497.

All New Choices Waiver providers must complete an Attachment B that corresponds to the New Choices Waiver service(s) that the provider is qualified to provide and intends to offer. If the provider plans to offer more than one New Choices Waiver service, the provider must complete a separate Attachment B for each of the distinct services. Just the final (signature) page of each Attachment B must be uploaded to the provider's file within the PRISM portal.

For Adult Residential Services providers including assisted living facilities, independent living facilities, community residential treatment facilities and small health care (Type N) facilities, if your facility offers more than one level of care it is important to complete a separate Attachment B for each/all of the residential levels of care that you are licensed or certified to provide. (For example, a licensed ALF with a secure memory care unit should complete an Attachment B for ALF Type 1 & 2 and a separate Attachment B for ALF secure memory care. Another example, a licensed ALF (non-memory care) that has a certified independent living wing should complete an Attachment B for ALF Type 1 & 2 and a separate Attachment B for certified independent living.)

For existing providers going through the validation process, it is very important that your PRISM provider enrollment file match up with existing New Choices Waiver provider enrollment records. Services that you have been approved to offer before now should be included in PRISM as well. If your PRISM file does not align with previously approved services, your application will be returned for edit. If you need to verify which service(s) your agency has signed up to offer through New Choices Waiver, please return to your provider file within the PRISM Portal and review this information in the section labeled "HCBS Waiver and EPAS." An Attachment B must be submitted for each of the services listed there.

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