Submit a request

Please select the most appropriate form from the list below.

Your email address

Subject: Please describe the issue you are reporting

Description: Please include details/pertinent information related to the item you are reporting.

A member of the Sandata support staff will respond to your request as soon as possible. If submitting after business hours, response will be on the next business day. If you have an urgent request, please contact the Customer support team at your agency's designated phone number.

Is this request for Connecticut DDS or DSS/DMHAS(optional)

Please select one of the following options

AVRS ID(optional)

DDS Provider ID (PIN)(optional)

Previous EVV STX#(optional)

Provider Name(optional)

Name(optional)

Email(optional)

Position/title(optional)

Phone number(optional)

Vendor List

If you do not see your alternate EVV Vendor organization in the drop-down list, select "Other (not listed)" to enter the name of your alternate EVV Vendor below.

Alternate EVV Vendor (Other)(optional)

Current or Previous Alternate EVV Vendor Name(optional)

If you do not see your alternate EVV Vendor organization in the drop-down list, select "Other (not listed)" to enter the name of your alternate EVV Vendor below.

Current or Previous Alternate EVV Vendor Name (Other)(optional)

New Alternate EVV Vendor Name(optional)

If you do not see your alternate EVV Vendor organization in the drop-down list, select "Other (not listed)" to enter the name of your alternate EVV Vendor below.

New Alternate EVV Vendor Name (Other)(optional)

New alternate EVV vendor contact name(optional)

New alternate EVV vendor contact email (optional)

New alternate EVV vendor contact position/title(optional)

New alternate EVV vendor contact phone(optional)

Current or Previous Alternate EVV Vendor Requested End Date (optional)

Proposed New Alternate EVV Vendor Requested Start Date(optional)

Proposed New Sandata Eletronic Visit Verification (EVV) Requested Start Date(optional)

Target date for ending use of Sandata EVV(optional)

Target date for ending use of Sandata Agency Management(optional)

Form ID(optional)

Attachments(optional)

Add file or drop files here

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