How to Become a Provider

The Area Agency on Aging, PSA2 contracts with agencies, non-agencies and Residential Care Facilities to provide services to PASSPORT, ComCare and Assisted Living Waiver consumers in Montgomery, Clark, and Greene Counties.  Only Ohio Department of Aging Certified providers are eligible for contracting.  Below are the application materials and Ohio Department of Aging rules for each service.

If, after reviewing the Conditions of Participation (173-39-02) and the Service Specifications (173-39-02.1 - 173-39-02.17) for the services you wish to contract for, you would like to submit an application, please print and complete the Application for Certification (ODA 1105) and the Medicaid Enrollment Application (JFS 06751).  Be sure to include all of the attachments requested on page 2 of the ODA 1105.

Send all of the materials to:

Cathie Hoffman, RN
Provider Relations Supervisor
6 S. Patterson Blvd.
Dayton, OH 45402