Pre-Contract Provider Application
Below is a pre-contract application that will assist us in learning more about your agency and determining potential services for our clients.
Is your agency licensed or accredited?
Please list the different types of services your agency currently provides and the hourly rate for these services:
For Home Health Services:
Do you currently work with persons with a brain injury?
Do you currently work with veterans and service members?
Is any of your clinical staff subcontracted?
If your agency does NOT have regulatory oversite (i.e. CARF, state licensure. JCAHO, etc.) please answer the following questions on annual checks and training.
Are ANNUAL checks conducted on:
Staff criminal background check?
Personal vehicle insurance verification?
Do you provide ANNUAL training on:
Crisis/incident documentation and reporting?
Emergency procedures (i.e. disaster training)?
Corporate compliance (i.e. corporate ethics and expectations)?
Are your staff CPR/FA certified through American Red Cross or American Heart Association?
Do you utilize a staff handbook to communicate your company policies and procedures?
If you do not provide these trainings, are you willing to implement these trainings for your contracted staff with NCC?
Has anyone affiliated with your agency ever been employed, contracted, sub-contracted or worked in a volunteer capacity with any of the following organizations? (Check all that apply)
In order to develop a contract and pursue services as a provider the following insurances are mandatory (scroll through all)
GENERAL LIABILITY INSURANCE
- $1 million/$3 million
- Include and list coverage for sexual abuse & molestation
- Add NCC and Wounded Warrior Project as “additional insureds”
AUTOMOBILE LIABILITY INSURANCE
- Either $1 million commercial or “hired and non-owned,” as applicable
WORKERS COMPENSATION INSURANCE
- Endorsed to contain a waiver of subrogation in favor of Neuro Community Care and Wounded Warrior Project
PROFESSIONAL LIABILITY INSURANCE