Join Our Provider Network

From Otsego to Sullivan, Schoharie to Broome, Southern Tier Connect knows our region and each unique community within it. We take pride in building dynamic personal relationships that connect people with intellectual and developmental disabilities to the highest quality services in the Southern Tier. Each partnership empowers each person we serve to realize their potential and lead the healthiest life possible.

Join Our Provider Network

Agency Name:*
Amount of Medicaid Service Coordinators ("MSC") currently employed:*
Amount of individuals who are provided MSC services with Intellectual and Developmental Disabilities:*
Counties in which the individuals are serviced:*
Agency Contact Person:*
First Last
Title:*
Phone:*
Email:*
Check if applicable:
- Agency desires to participate as a Member and financial partner of Southern Tier Connect, LLC OR...
- Agency desires to participate as a MSC service provider on behalf of Southern Tier Connect, LLC
Digital Signature*
Title*
Date*
MM slash DD slash YYYY

Network Provider Agreement

Network Partner Agreement

This is to confirm that*

(name of network partner/organization)
located at*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

(address of network partner/organization)
has agreed to be a provider in the network of Southern Tier Connect. As a member of the network, you will receive referrals and provide services (e.g., behavioral health, physical health, social and community supports, specialty children’s services, developmental disability services, and other long term supports and services) and collaborate and support the work of the CCO/HH care managers who will develop Life Plans for individuals with intellectual and/or developmental disabilities who will be enrolled in and receive Health Home care management through Southern Tier Connect.
List of Affiliated Health Care or I/DD Organizations under this agreement:*
Additional Providers under this agreement (if applicable):
Name of Authorized Representative*
First Last
Authorized Representative for Southern Tier Connect*
First Last
Signature
Title*
Title*
I acknowledge by initialing below that I am entering into an agreement on behalf of my organization with Southern Tier Connect. I further agree that I am authorized to enter into agreements on behalf of my organization and have completed this agreement accurately to the best of my knowledge.*

Please type your initials into this box to verify your participation in this agreement.