Exit

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* Provider Legal Name (to appear on contract)

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* Name & Title of Person(s) completing this application

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* Is your company incorporated?

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* State in which incorporated

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* Incorporation date

Date

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* Type of Corporation (Sole Proprietor, Nonprofit, LLC, etc)

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* Federal ID Number

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* Please select one

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* Lead ASAP for Provider Frail Elder Waiver Enrollment

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* Check if NOT enrolled as FEW Provider

Additional employee details (provide contact information for the following positions):
Person Authorized to Sign Contract:

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* Name

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* Title

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* Phone

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* Fax

Intakes and Scheduling:

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* Name

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* Title

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* Phone

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* Fax

Client Issues/Complaints:

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* Name

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* Title

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* Phone

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* Fax

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* Check to confirm that your company conducts training upon hire and annually on Mandated Reporting, Confidentiality, and Infection Control.

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* If No, please provide explanation

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* Check to confirm that your company complies with guidelines set forth my the Executive Office of Technology Services and Security.

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* If No, please provide explanation

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* Indicate the towns in which you are able to provide service (with routine and back-up delivery)

Service Rate Proposals
Please be aware that certain rates are set by EOHHS and cannot be negotiated.  Hourly services with 15-minute unit rates must be divisible by 4.  

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

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* Please select a service

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* Rate

Document Uploads (Note: PDF format only; 16MB limit)

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* Notice of intent Letter (introduce your company and the services you wish to contract for)

PDF file types only.
Choose File

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* Unit Rate Calculation Page and/or provide methodology for proposed rates

PDF file types only.
Choose File

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* Administrative Overview

PDF file types only.
Choose File

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* Service Specific Attachments (as one file)

PDF file types only.
Choose File

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* W-9

PDF file types only.
Choose File

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* Supplier Diversity Program Certificates if applicable

PDF file types only.
Choose File

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* Written Information Security Plan (WISP)

PDF file types only.
Choose File

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* Certificate(s) of insurance showing professional, general and workers' compensation coverage

PDF file types only.
Choose File

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* Uniform Financial Statements of Exemption Reason

PDF file types only.
Choose File

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* Short Form of Legal Existence

PDF file types only.
Choose File

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* Policies & Procedures

PDF file types only.
Choose File
Upload all policies & procedures listed below under one file. Please ensure you include  ALL required documents from the list below which are applicable to the services your company provides.

All Providers:
a. Personnel Policies, including supervision, annual performance evaluation, work rules, etc.
b. Conflict of Interest
c. Privacy and Confidentiality
d. Non-discrimination in employment and service delivery
e. MassHealth All Provider Bulletin 196: The Office of the Inspector General’s List of Excluded Individuals and Entities
(required upon hire and annually)
f. CORI (PI-09-19)
g. Reportable Incidents
h. Consumer Not at Home Policy
i. Emergencies in the Home
j. Theft, Loss, or Damage to Consumer Property
k. Prohibitions on Fees and Gratuities
l. Prevention and Detection of Medicaid Fraud, Waster, & Abuse
m. System for Award Management (SAM) federal provider exclusion checks (required upon hire and annually)
n. Massachusetts Excluded/Suspended provider checks (required upon hire and annually)
o. Attach copies of job descriptions for all positions related to the contract
Additional Questions for Homemaker/Personal Care Providers Only

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* Does your company provide Homemaker/Personal Care services

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* Has your company implemented Electronic Visit Verification (EVV)?

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* If no EVV, provide expected implementation date

Date

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* Upload your company's policy/procedures for EVV compliance

PDF, DOC, DOCX, PNG, JPG, JPEG, GIF file types only.
Choose File

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* EVV Manager Name & Telephone #

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* Does your company comply with quarterly Home Care Worker Registry (HCWR) updates?

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* If no HCWR compliance, provide explanation

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* Upload your company's policy/procedures for HCWR compliance

PDF file types only.
Choose File

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* HCWR Manager Name & Telephone #

Please ensure the application is completed in full. Incomplete applications may not be considered for provider agreements.
 
 100% of survey complete.

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