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* 1. Provider Name

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* 2. Name of person authorized to sign the contract

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* 3. E-mail of person authorized to sign the contract

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* 4. Primary contact for in-home services

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* 5. E-mail of primary contact for in-home services

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* 6. Primary contact for billing related correspondence

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* 7. E-mail of primary contact for billing related correspondence

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* 8. Mailing Address

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* 9. Phone Number

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* 10. Please check the services your agency is able to provide (check all that apply)

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* 11. Please list the counties you are prepared to serve

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* 12. Are there any changes in coverage area from last year?

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* 13. If yes, please explain the changes.

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* 14. Will your agency's private pay rates  for homemaker be the same or more than the State's reimbursement rates?

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* 15. Will your agency's private pay rates for personal care be the same as or more than the State's reimbursement rates?

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* 16. Will your agency's private pay rates for nursing be the same as or more than the State's reimbursement rates?

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* 17. Will your agency's private pay rates for adult companion be the same as or more than the State's reimbursement rates?

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* 18. Will your agency's private pay rates for respite be the same as or more than the State's reimbursement rates?

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* 19. Will your agency's private pay rates for chore be the same as or more than the State's reimbursement rates?

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* 20. If your private pay rate is less than the State's reimbursement rate, please list EACH service you provide and your private pay rate for each service.

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* 21. Additional Comments:

0 of 21 answered
 

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