Provider Application

Instructions: Please complete this application as the first step in the process of becoming a community partner to provide services for warriors enrolled in the WWP Independence Program.

NRM Provider Application

Provider Information

Full Legal Name of Agency

DBA

Federal Tax ID Number (EIN):

Organizational Structure (i.e. LLC, S Corp, C Corp, Non-Profit, etc.):

Provider Status

Independently Owned

Affiliate

Physical Address

Phone

Mailing Address

FAX

Billing Address

Website

Primary Email Address

Incorporation Date* *Note: Organization must be in operation for at least one full year to be eligible for contracting.

Corporation Affiliation (If Applicable)

Physical Address

Phone

Mailing Address

FAX

Billing Address

Website

Primary Email Address

Contacts

Individual Completing this Form

Phone

Title

Individual Authorized to Sign Contract

Phone

Title

AR Representative

Phone

Title

Licensing/Accreditation Summary

Accredited?

Yes

Accrediting Agency

Current State Licenses (List if applicable)

Service Summary

List all States/Cities/Counties Currently Serving

For HHA Agencies ONLY: State Specific regulatory Requirements

Specialty Services

Bowel & Bladder Care

Wound Care

Hoyer Lift

Vent Care

Other:

Service Rates($ per hour)

Community Support Specialist (CSS):

Case Management/Case Supervision:

HHA Assessment/RN Supervision (If required):

HHA OT/Holidays/Weekends (If applicable):

HHA Services:

Additional Information

# of hours:

Program Director

Note: The program director will be asked to participate in the phone interview regarding the agency’s policies and procedures as part of the vetting process.

Program Director Name

Title

Phone

CSS/HHA Supervisor

Note: Name of the individual who will directly supervise the CSS/HHA. CSS Supervision requires availability to provide direction/support to the CSS, participation in team calls, and oversight of activity logs and invoicing.

Supervisor Name

Title

Phone

Experience

Agency’s experience working with individuals with disabilities and populations served:

Agency’s experience working with individuals who have brain injuries:

Agency’s experience working with veterans:

Agency’s experience providing CSS and/or HHA services to individuals:

Is the agency currently providing CSS and/or HHA services to warriors referred by Neuro-Community Care (NCC)?

Yes

Staff Summary

Total Number of Employees

Number of Home Health Aides:

Number of Licensed/Credentialed Staff

Number of Community Support Specialists:

Specialities

Check all activities completed before hire:

Criminal Background Check

Vehicle Insurance Verification

Driving Record Check

Insurance Requirements

In order to develop a contract and pursue services as a provider, the following insurances are mandatory.

A. Commercial general liability insurance, including products and completed operations, with at least ONE MILLION DOLLARS ($1,000,000.00) per occurrence limit of liability and THREE MILLION DOLLARS ($3,000,000.00) aggregate limit of liability. Such insurance shall include coverage for sex abuse or molestation no less broadly than under ISO Form No. CL CG 00 06 01 04. Contractor shall add NRM and Wounded Warrior Project, Inc. ("WWP") as additional insureds under such policy, and such additional insurance shall be provided on a primary and non-contributory basis.

Commerical GL - Does your existing coverage meet these requirements?

Yes

B. Automobile liability insurance (either commercial or "non-owned and hired," as applicable) with at least ONE MILLION DOLLARS ($1,000,000.00) combined single limit, covering any and all automobiles owned, operated, leased, or hired by Contractor.

Auto - Does your existing coverage meet these requirements?

Yes

C. Workers' compensation insurance as required by applicable law. Such insurance shall be endorsed to contain a waiver of subrogation in favor of NRM and WWP.

W/C - Does your existing coverage meet these requirements?

Yes

D. Professional liability insurance with at least ONE MILLION DOLLARS ($1,000,000.00) per claim and THREE MILLION DOLLARS ($3,000,000.00) in the aggregate. Such professional liability insurance will afford coverage with respect to all Services provided under this Agreement that are professional services.

Prof. Liab. - Does your existing coverage meet these requirements?

Yes

If you answered no to any of the above, the organization must be willing to obtain and/or increase coverage as needed to move forward in the contracting process.

Are you willing to obtain/increase coverage to meet these requirements?

Yes

Is there anything else you would like us to know about your organization?

Thank you for completing a NRM Provider Application. Your application will be reviewed, and you will be contacted by a NRM representative within 3-5 business days.