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. Full Legal Name of Agency: * Name of Person Completing Form: * NCC Staff Who Referred You (If applicable) Address * Address Address Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Telephone number * Email * Telephone Number: * Web Addess: * Is your agency licensed or accredited? * Yes No If so, please specify: Please list the different types of services your agency currently provides and the hourly rate for these services: Service * Rate/Hr. * Service Rate/Hr. Service Rate/Hr. Service Rate/Hr. For Home Health Services: Please list hourly rates for nights, weekends, and holidays: What is the start/end time of the night shift? What is the start/end time of the weekend shift? If there are holiday rates, what holidays are observed by your agency? Is there an initial assessment fee? If so please list the rate: What is your proposed bill rate/hr. for a Community Support Specialist? Do you currently work with persons with a brain injury? * Yes No Do you currently work with veterans and service members? * Yes No What other population(s) do you serve? * List the geographical area(s) where you currently provide services (State/Cities/Counties) * How long have you been in business? * How many total staff work for your agency? * How many clinical staff work for your agency? * Is any of your clinical staff subcontracted? * Yes No If so, please explain: Please describe the type of training you provide to new clinical staff during onboarding: * Is there anything else you would like us to know about your agency? * 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? Yes No Personal vehicle insurance verification? Yes No Staff driving records? Yes No Do you provide ANNUAL training on: HIPAA? Yes No Confidentiality? Yes No Ethics? Yes No Code of conduct? Yes No Crisis/incident documentation and reporting? Yes No Emergency procedures (i.e. disaster training)? Yes No Abuse and neglect? Yes No Mandated reporting? Yes No Corporate compliance (i.e. corporate ethics and expectations)? Yes No Defensive driving? Yes No Are your staff CPR/FA certified through American Red Cross or American Heart Association? Yes No Do you utilize a staff handbook to communicate your company policies and procedures? Yes No If you do not provide these trainings, are you willing to implement these trainings for your contracted staff with NCC? Yes No 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) * Neuro Community Care, Wake Forest, NC Neuro Rehab Management, Boston, MA Wounded Warrior Project Unsure If you checked any of the organizations above, please provide the following information: Dates of employment: Name of employee or subcontractor: In what position? 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 $1 million/$3 million Next
