Home Care Credentialing Application
Provider Information
Legal Name of Provider/ Organization:
Type of Provider/ Organization:
Doing business as (DBA) or other names, if applicable:
Tax Identification Number (TIN) / Employer Identification Number (EIN):
State(s) Organization is Registered:
State(s) Licensed to Conduct Business:
Please indicate the NPI(s) associated with the TIN/EIN provided above:
National Provider Identifier (NPI):
Contact Information
Physical Business Address
If your organization has multiple physical locations to credential under a single TIN/EIN, please list each using the "Add" option below
Address Line
City
State
Postal Code
Country
Please select...
Afghanistan
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
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
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
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Billing (Pay To) Address, if different from Physical Business Address
Billing (Pay To) Address, if different from Physical Business Address
The billing contact is the provider contact responsible for batching and posting invoices in the homeAlign platform. This contact will also serve as the primary contact for provider payments. The billing contact receives all invoice and billing-related system notifications from homeAlign platform.
Billing/ Accounting Point of Contact, if different from Primary
Billing/ Accounting Point of Contact
Full Name
Phone Number
Alt Phone Number
Email Address
Address Line
City
State
Postal Code
Country
Please select...
Afghanistan
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
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei
Bulgaria
Burkina Faso
Burundi
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
Côte d ' Ivoire
Croatia ( Hrvatska )
Cuba
Cyprus
Czech Republic
Congo ( DRC )
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands ( Islas Malvinas )
Faroe Islands
Fiji Islands
Finland
France
French Guiana
French Polynesia
French Southern and Antarctic Lands
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Honduras
Hong Kong SAR
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao SAR
Macedonia, Former Yugoslav Republic of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Korea
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russia
Rwanda
Samoa
San Marino
São Tomé and Prìncipe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Spain
Sri Lanka
St. Helena
St. Kitts and Nevis
St. Lucia
St. Pierre and Miquelon
St. Vincent and the Grenadines
Sudan
Suriname
Svalbard and Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
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
Viet Nam
Virgin Islands ( British )
Virgin Islands
Wallis and Futuna
Yemen
Zambia
Zimbabwe
Primary Point of Contact (Name of Person Completing the Form)
The primary contact is the main point of contact for homeAlign, insurance carriers, and clients when the provider needs to be reached. This contact receives ALL system notifications from the homeAlign platform.
Full Name
Phone Number
Alt Phone Number
Email Address
Is the referral point of contact different from primary?
Yes
No
Is the credentialing point of contact different from primary?
Yes
No
Referral Point of Contact (if different from primary)
The referral contact is the provider contact associated with management of homeAlign service referrals. The referral contact receives all referral-related system notifications, such as referral assignment and referral escalation notifications.
Full Name
Phone Number
Alt Phone Number
Email Address
Credentialing Referral Point of Contact (if different from primary)
The credentialing contact is the provider contact who homeAlign works with throughout the credentialing and re-credentialing process. This contact will also be the primary contact for any compliance or credentialing-related escalations. The credentialing contact receives all credentialing-related system notifications from the homeAlign platform.
Full Name
Phone Number
Alt Phone Number
Email Address
Counties or Zip Codes Serviced:
Scope of Services (select all applicable):
RN Assessments
Personal Care Services
Companionship
Home Health Care
Homemaker Services
Other
Other services:
Are you currently accredited by any accrediting bodies?
Yes
No
Name of Accreditation:
Number:
Expiration Date
Have there been any restrictions, actions, or sanctions on your licensure, certification, or registration in the past five years?
Yes
No
Please provide details:
And/ or upload pertinent documentation:
Has your organization lost its accreditation, been denied accreditation, or otherwise been sanctioned by the accrediting body within the last five years?
Yes
No
Have criminal proceedings ever been initiated against your company or its authorized representatives?
Yes
No
Have there ever been any liability claims history or lawsuits, or are there currently any pending against your company, or have judgments been made or settlements paid on its behalf in the past five years?
Yes
No
Has there ever been any disclosure of complaints or adverse action reports filed with a local, state, or national professional society or licensing board?
Yes
No
Does your organization require the use of Electronic Verification for services or visits?
Yes
No
Which system do you use?
Due to contractual obligations, contractors may not be utilized to provide services to clients. Can you please confirm only employees of the agency with provide services?
Yes
No
Does your company maintain policies procedures for the following:
Yes
No
Verification that prospective employees are authorized to work in the US:
Verification that prospective employees are at least 18 years of age:
Verification of prospective employee work history:
State Criminal Background Check:
OIG List of Excluded Individuals and Entities Check:
Employee training:
Credentialing documentation:
To expedite the credentialing process, please provide details and/or upload pertinent documentation:
State license for home care
(If required by the state)
W-9
Certificate of Insurance (COI)
a. General Liability
b. Workers Compensation (If you are not required to have these insurances per your state, please respond with "not required for our agency.”)
Copy of the following agency policies:
a. Pre-Employment Screening
b. Criminal Background Check (Should include a criminal history check)
c. Client Confidentiality/HIPAA (Policy must detail PHI procedures)
d. Fraud, Waste, and Abuse (Regarding defrauding, deception, or mismanagement of client billing and/or visits)
Documentation Upload (supports multiple file upload):
Credentialing Documentation:
To expedite the credentialing process, please upload the following documentation
(if applicable).
Multiple files supported by selecting
"
Upload additional licensure documentation"
1. State license for home care
If licensure is not required per your state, please select "not required by the state.”
Add additional files by selecting "Upload additional..." below
Not required by the state
2. W9
3. Certificate of Insurance (COI)
a. General Liability
b. Workers Compensation
If these insurances are not required per your state, please select "not required by the state.”
Upload additional licensure documentation
Not required by the state
4. Copy of the following agency policies:
a. Pre-Employment Screening
b. Criminal Background Check (Should include a criminal history check)
c. Client Confidentiality/HIPAA (Policy must detail PHI procedures)
d. Fraud, Waste, and Abuse (Regarding defrauding, deception, or mismanagement of client billing
and/or visits)
Provide additional comments if needed:
I attest that the information provided on the Credentialing Application is true and accurate.
By checking this box, you are attesting to the fact that, to your knowledge, all information presented in this application is true and accurate.
Name:
Date:
Title:
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