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Home Health Care Provider Questionnaire

Please complete form and send to Network Relations Department.

Legal Company Name:
D/B/A Name
Physical Address
  City
State Zip
Remit to Address
  City
State Zip
Phone
Alternate Phone
Fax
Email
Website
Contact Person & Title
Counties Served
Years in Business
Hours of Operation
Federal Tax ID
Delivery Hours?
Do you offer on call services? Yes No
Required to have State License to provide services? Yes No
Certification Held
Do you have processes in place to verify current
licensures and certifications? Yes No
Do you subcontract any of your services? Yes No
If yes, What services and who credentials these subcontractors?
What item(s) do you supply from your in-house inventory?

Hourly Services RN LPN HHA/CNA
Visit Services (2 hours or less) RN LPN HHA/CNA
Wound Vacs BlueSky Medical KCI
Wound Care
Infusion/IV Therapy
Physical Therapy
24 hour/Live -in Aide
Occupational Therapy
Homemaker/Companion Care
Speech Therapy
Speak a Foreign Language
Other


I attest that the information on this application is correct and complete. I agree to notify Total Medical Solutions within 30 days of any changes to the information contained herein.