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 Afghanistan Aland Islands Albania Algeria American Samoa Andorra Angola Anguilla Antarctica Antigua and Barbuda Argentina Armenia Aruba Australia Austria Azerbaijan Bahamas Bahrain Bangladesh Barbados Belarus Belgium Belize Benin Bermuda Bhutan Bolivia Bonaire, Sint Eustatius and Saba Bosnia and Herzegovina Botswana Bouvet Island Brazil British Indian Ocean Territory Brunei Bulgaria Burkina Faso Burundi Côte d'Ivoire Cambodia Cameroon Canada Cape Verde Cayman Islands Central African Republic Chad Chile China Christmas Island Cocos (Keeling) Islands Colombia Comoros Congo Cook Islands Costa Rica Croatia Cuba Curacao Cyprus Czech Republic Denmark Djibouti Dominica Dominican Republic East Timor Ecuador Egypt El Salvador Equatorial Guinea Eritrea Estonia Ethiopia Falkland Islands (Malvinas) Faroe Islands Fiji Finland France French Guiana French Polynesia French Southern Territories Gabon Gambia Georgia Germany Ghana Gibraltar Greece Greenland Grenada Guadeloupe Guam Guatemala Guernsey Guinea Guinea-Bissau Guyana Haiti Heard Island and McDonald Islands Holy See Honduras Hong Kong Hungary Iceland India Indonesia Iran Iraq Ireland Isle of Man Israel Italy Jamaica Japan Jersey Jordan Kazakhstan Kenya Kiribati Kosovo Kuwait Kyrgyzstan Laos Latvia Lebanon Lesotho Liberia Libya Liechtenstein Lithuania Luxembourg Macao Macedonia Madagascar Malawi Malaysia Maldives Mali Malta Marshall Islands Martinique Mauritania Mauritius Mayotte Mexico Micronesia Moldova Monaco Mongolia Montenegro Montserrat Morocco Mozambique Myanmar Namibia Nauru Nepal Netherlands New Caledonia New Zealand Nicaragua Niger Nigeria Niue Norfolk Island North Korea Northern Mariana Islands Norway Oman Pakistan Palau Palestine Panama Papua New Guinea Paraguay Peru Philippines Pitcairn Poland Portugal Puerto Rico Qatar Reunion Romania Russia Rwanda Saint Barthelemy Saint Helena, Ascension and Tristan da Cunha Saint Kitts and Nevis Saint Lucia Saint Martin (French part) Saint Pierre and Miquelon Saint Vincent and the Grenadines Samoa San Marino Sao Tome and Principe Saudi Arabia Senegal Serbia Seychelles Sierra Leone Singapore Sint Maarten (Dutch part) Slovakia Slovenia Solomon Islands Somalia South Africa South Georgia and the South Sandwich Islands South Korea South Sudan Spain Sri Lanka Sudan Suriname Svalbard and Jan Mayen Swaziland Sweden Switzerland Syria Taiwan Tajikistan Tanzania Thailand Timor-Leste Togo Tokelau Tonga Trinidad and Tobago Tunisia Turkey Turkmenistan Turks and Caicos Islands Tuvalu Uganda Ukraine United Arab Emirates United Kingdom United States United States Minor Outlying Islands Uruguay Uzbekistan Vanuatu Vatican City Venezuela Vietnam Virgin Islands, British Virgin Islands, U.S. Wallis and Futuna Western Sahara Yemen Zambia Zimbabwe 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. Service Rate/Hr. 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 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? * Yes No If no, are you willing to obtain them? * Yes No If you are human, leave this field blank. Next
