Become a Provider

Becoming a Provider

Becoming a Provider

Pre-Contract Provider Application

Below is a pre-contract application which will assist us in determining more about your agency and the potential to provide services for our clients.

Address *
Address
City
State/Province
Zip/Postal
Country
Is your agency licensed or accredited? *

Please list the different types of services your agency currently provides and the hourly rate for these 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?
Staff driving records?
Do you provide ANNUAL training on:
HIPAA?
Confidentiality?
Ethics?
Code of conduct?
Crisis/incident documentation and reporting?
Emergency procedures (i.e. disaster training)?
Abuse and neglect?
Mandated reporting?
Corporate compliance (i.e. corporate ethics and expectations)?
Defensive driving?
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) *

If you checked any of the organizations above, please provide the following information:

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 coverage for sexual abuse and molestation

AUTOMOBILE LIABILITY INSURANCE
Either $1 Million commercial or "hired and non-owned" as applicable

WORKERS COMPENSATION INSURANCE
Coverage for ALL employees or those doing business on your behalf

PROFESSIONAL LIABILITY INSURANCE
$1 Million/ $3 Million

Do you have these insurances? *
If no, are you willing to obtain them? *