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

Provider Status

Corporation Affiliation (If Applicable)

Contacts

Licensing/Accreditation Summary

Accredited?

Current State Licenses (List if applicable)

Service Summary

List all States/Cities/Counties Currently Serving

For HHA Agencies ONLY: State Specific regulatory Requirements

Licensing Specifications
Specialty Services

Other:

Service Rates($ per hour)

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.

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.

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)?

Staff Summary

Check all activities completed before hire:

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?
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?

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?

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?

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?

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.