The DP 1059 provider qualification form is Pennsylvania’s Office of Developmental Programs (ODP) document that verifies you meet state standards to deliver services under the Consolidated, Community Living, Person/Family Directed Support, and Adult Autism waivers. To use it, download the current version from MyODP, complete Sections 1 through 3, attach the Provider Qualification Documentation Record with supporting materials, and email the package to your Assigned Administrative Entity (AE). The current form is dated April 14, 2025, and the same process applies to agencies and individual practitioners.
Download the Current Version
Get the form from the MyODP Provider Qualification and Enrollment page, which also hosts the instruction sheet.1MyODP. Provider Qualification and Enrollment An older v.2 still appears on the MyODP Forms page; using it can get your submission returned, so pull the most recent dated version.2MyODP. Forms
What to Have Ready Before You Start
Assemble these before opening the form:
- Your Master Provider Index (MPI) number, if you have one. New applicants without an MPI leave the field blank.
- Your 10-digit National Provider Identifier (NPI). If you don’t have one, apply through the NPPES registry, which requires at least one taxonomy code and a practice location.3NPPES. Apply for an NPI
- Your Federal Employer Identification Number (FEIN) from the IRS.
- Current training certificates, professional licenses, and proof of insurance. These attach to the Documentation Record rather than the DP 1059, but you’ll need them ready for the full package.
Filling Out Sections 1 Through 3
The form has four sections. You complete Sections 1 through 3; the AE fills in Section 4 after review.4MyODP. Provider Qualification Form (DP 1059) Instructions
Section 1: Provider Information
Enter your provider name exactly as it appears in IRS records. A mismatch will flag the application. Fill in the MPI if you have one. Enter the name, title, phone, and email of the CEO or designee completing the form, and select “CEO” or “Designee” from the pull-down.
Add your business street address, city, state, and zip. Choose your Assigned AE from the pull-down. New applicants pick the AE in the county where they plan to serve the most individuals; existing providers select the AE ODP has already assigned. Enter the submission date.
Section 2: Provider Attestations
Section 2 is a series of compliance statements. Read each one and mark “Yes” or “No” based on whether your organization can meet the standard. The CEO’s typed name at the bottom certifies that every answer is accurate. Enter the date the attestations were answered. A “No” is not automatic disqualification, but expect the AE to ask about it, so be ready to explain or correct.
Section 3: Qualification Determination of Services
This is where you list the services you want to be qualified to deliver. Use the pull-downs to select each Provider Type (PT) and Specialty pairing. The codes appear numerically and map to waiver services such as residential habilitation, companion services, and respite. If you want an enhanced level for a specialty, mark “Yes” in the Enhanced Level column; for specialties without an enhanced tier, the box auto-fills to “No.”
Each PT/Specialty line has a comments field for enhanced-level notes, and an overall comments box at the end of the section covers anything else the AE should see. Pick specialties carefully. You can resubmit the DP 1059 later to add specialties, but every resubmission goes back through AE review.5Pennsylvania Department of Human Services. ODP Announcement 25-014 – Provider Qualification Process
The Provider Qualification Documentation Record
The form alone is not enough. You must also complete the Provider Qualification Documentation Record and attach the supporting materials that show you meet ODP’s standards.6Pennsylvania Department of Human Services. ODP Announcement 25-013 – Qualification Process for New Intellectual Disability/Autism Provider Applicants Update The Record spells out what’s required for each specialty you selected.
Documentation varies by specialty but commonly includes current training certificates, valid professional licenses (nursing, therapy, or behavioral health credentials), proof of liability insurance, and organizational policies aligned with 55 Pa. Code Chapter 6100.7Cornell Law Institute. Pennsylvania Code 55 Pa. Code 6100.81 – HCBS Provider Requirements Providers operating as an Organized Health Care Delivery System (OHCDS) also include vendor qualification information for any vendor goods or services.5Pennsylvania Department of Human Services. ODP Announcement 25-014 – Provider Qualification Process
Provider Applicant Orientation for New Providers
New applicants, but not re-qualifying providers, must complete the ODP Provider Applicant Orientation before qualification. The orientation is free and runs through the MyODP learning platform. Only the CEO or Executive Director can complete it; the task cannot be delegated.8MyODP. Provider Applicant Orientation
Watch the clock. The Orientation Certificate of Completion expires if you’re not qualified within 120 days of the certificate date.9Department of Human Services. ODP Provider Qualifications If the AE hasn’t finished reviewing your package by then, you’ll have to redo the orientation. Start the paperwork as soon as your certificate is issued.
Where to Submit the Package
Send your completed DP 1059, the Provider Qualification Documentation Record, and all supporting documents to your Assigned AE, meaning the AE in the county where you intend to serve the most individuals.10Pennsylvania Department of Human Services. ODP Announcement 19-044 – Updated Qualification Process for New Providers Email is the standard method; ODP Announcement 19-044 instructs applicants to forward all documentation via email to the Assigned AE.
A list of Administrative Entities by county sits on the Pennsylvania Department of Human Services website. The DHS ODP Provider Qualifications page has guidance and contacts if you’re unsure which AE covers your primary service area.9Department of Human Services. ODP Provider Qualifications
Review Timeline and Section 4
For new applicants, the AE has 30 calendar days from receipt to review and validate your documentation.10Pennsylvania Department of Human Services. ODP Announcement 19-044 – Updated Qualification Process for New Providers Expect follow-up questions or requests for more documents inside that window. Reply quickly; delays cut into the 120-day orientation certificate.
The AE completes Section 4, marking each specialty “Qualified” or “Not Qualified,” signs the form, and emails the finalized version back to you.5Pennsylvania Department of Human Services. ODP Announcement 25-014 – Provider Qualification Process Your status then appears in the Home and Community Services Information System (HCSIS). New providers show as “New” until they complete their first re-qualification cycle on July 1, when the status updates to “Existing.”
PROMISe Enrollment Before You Can Bill
Qualification does not let you bill. To receive payment, you also enroll in PROMISe, Pennsylvania’s Medicaid management information system. After the AE qualifies you, ODP’s enrollment team reviews the application and adds your approved specialties to the HCSIS Provider Qualification Status Screen based on the PROMISe effective date. Written verification from PROMISe usually arrives within about a week, confirming the enrolled specialties.5Pennsylvania Department of Human Services. ODP Announcement 25-014 – Provider Qualification Process
Once your specialties show in HCSIS, you can update your service offerings, have rates assigned, and receive service authorizations on Individual Service Plans (ISPs). If you add a new specialty later through a resubmitted DP 1059, that specialty will not appear in HCSIS until a separate PROMISe enrollment is completed. New service locations go through the Online Provider Enrollment Application System.
Re-Qualification Deadlines
Qualification is not permanent. Existing providers must re-qualify by submitting an updated DP 1059 and Provider Qualification Documentation Record with supporting materials to the Assigned AE by March 31 of the year re-qualification is due. The AE completes review and returns the finalized DP 1059 by June 30.5Pennsylvania Department of Human Services. ODP Announcement 25-014 – Provider Qualification Process
If you have not been re-qualified by May 1, which is 60 days before the June 30 end date, HCSIS automatically changes your status to “Expiring.” Falling out of qualified status ends your ability to receive service authorizations and bill through the waiver system, which disrupts services for the individuals you support. Separately, service locations are revalidated through PROMISe every five years from initial enrollment, using the Online Provider Enrollment Application System, under 42 CFR 455.414.11eCFR. Revalidation of Enrollment
What False Information on the Form Costs
The Section 2 attestations carry real weight. Under 18 Pa. C.S. ยง 4904, a written false statement made to mislead a public servant is unsworn falsification to authorities, a second-degree misdemeanor.12Pennsylvania General Assembly. Pennsylvania Code 18 Section 4904 – Unsworn Falsification to Authorities Conviction carries up to two years of imprisonment and a mandatory minimum fine of $1,000, with fines up to $5,000.13Pennsylvania Code and Bulletin. 101 Pa. Code 15.66 – Penalties for Offenses A false filing would also almost certainly mean disqualification from the ODP system and exclusion from billing any waiver services. Treat the attestations as sworn statements.