Add a Provider to the Map

This form can be used by new or existing participant providers to request to be added to the map.

Upon approval, information will be submitted to our web developer and the location(s) will be added within 3-5 business days.

Company Name URL

Company Name *

Location

Website / URL

Address

Address Line 1

Address Line 2

City

--- Select state ---AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone

Services Selection (Select all that apply)

• Accepts Medicaid
• Diagnostic Services
• In-Home ABA Treatment
• In-Clinic ABA Treatment
• Social Skills Group
• Scholarship Provider (ASP or JP)
• Adult Day Services (Waiver)
• Adult ABA (Focused Intervention)
• After School Services (In-Clinic)
• Evening Services (M-F)
• Weekend Services
• Waiver HPC or Respite Services
• OhioRise Respite Services

Additional Information

Please provide any other useful information about your practice here.

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