__Document:
Agency Information Form
Description:
General Provider agency information required for contracting and ongoing outreach.
Directions:
Please indicate information and return upon completion.
Agency Information Form
1.
Agency Type (Please Select All Applicable):
Home Health Agency
Durable/Home Medical Equipment
Specialty Pharmacy for Infusion Therapy
Other
2.
Reason for Request (Please Select All Applicable):
New Network Provider Agreement
Add to Existing Network Agreement
Other
3.
Legal Agency Name:
4.
Doing Business As (DBA) Name:
5.
Ownership Entity or Group Name (If Applicable):
6. Multiple Facilities:
_____ NO
_____ / _____ YES / Number of Branches
If YES, Please complete Attachment A for each branch.
If Yes, Do You Have Centralized Contracting? ___ NO
___ YES (If Yes, provide contact information in space
below)
7.
Primary Contact Name:
Authorized Provider Official? ___ NO
___ YES
Title:
Email Address:
Phone Number:
8.
Agency Primary Address:
City:
State:
Zip Code:
9.
Agency General Contact Information:
Website:
Email:
Telephone:
Fax:
10. Federal Tax I.D. #:
11. National Provider Identifier #:
12. State License #:
Expiration Date:
13. CMS Certification # (If Certified):
14. Medicaid # (If Certified):
15. Census – Average Daily:
16. Census – Full Capacity:
17. Have you had any Medicare/Medicaid sanctions within the past 10 years?
_____ NO
_____ YES
If YES, Are these Sanctions still active? _____ NO
_____ YES
________ Sanction Expiration Date
18. Is your Agency Accredited? If so, by whom and when does the accreditation expire?
FOR QUESTIONS OR TO SUBMIT FORM, PLEASE RETURN TO ATTN: PROVIDER NETWORK:
VIA FAX AT 615-988-9947
VIA EMAIL AT
OR
Version 1.3 20170117