Developmental Disabilities, Medically Fragile and Supports Waiver Provider Enrollment

This section provides all the details on applying to become a provider for the Developmental Disability Waiver (DD), Medically Fragile (MF) and Supports Waivers (SW).

Application Documents

The documents below will assist you with the application process.

• DDW/MFW/SW Provider Agreement Amendment Form
• DDW/MFW/SW Provider Agreement Form
• DDW/MFW/SW Self-Imposed Moratorium Form
• Developmental Disabilities (DD) Waiver Provider Application
• Developmental Disabilities (DD) Waiver Provider Application Forms
• Medically Fragile (MF) Waiver Provider Application
• Medically Fragile (MF) Waiver Provider Application Forms
• Supports Waiver (SW) Provider Application
• Supports Waiver (SW) Provider Application Forms

Service Standards

The following links contain helpful information for both first-time and current providers.

• DDW Service Standards
• Medically Fragile Service Standards
• Supports Waiver Service Standards

Billing

For billing assistance, contact Conduent at 1-800-299-7304 or via email at NM.Providers@hsd.nm.gov.

• MFW Rate Table
• DDW Rate Table
• Supports Waiver Rate Table

Secondary Freedom of Choice

The Secondary Freedom of Choice (SFOC) form is utilized by case management provider agencies to present to registrants when selecting DDW, MFW and Supports Waiver services.

To request a SFOC form, please contact us at cpb.peu@state.nm.us.

Policy and Procedure Exception Request

Pursuant to the SFOC Policy and Procedure, provider agencies cannot not deny services to any individual once a SFOC has been signed, unless they can demonstrate that they do not have the capability to ensure the health and safety of that individual.

If your agency has received a signed SFOC and is unable to accept the individual for the reasons outlined within the SFOC Policy and Procedure, please fax a copy of the SFOC Policy & Procedure Exception Request Form to one of our Regional Offices for review.