Home Care Credentialing Application

Provider Information

Legal Name/Entity Name of Provider:

Type of Provider/ Organization:

Doing Business As (DBA), if applicable:

Franchise name, if applicable:

State(s) Organization is Registered:

State(s) Licensed to Conduct Business:

Employer Identification Number (EIN):

Does your organization have multiple physical locations to onboard?

YesNo

National Provider Identifier (NPI):

Please indicate the NPI associated with the EIN provided

Contact Information

National Provider Identifier (NPI) for this location:

Please indicate the NPI associated with the TIN/EIN provided

Physical Business Address

Address Line

City

State

Postal Code

Country

Billing (Pay To) Address, if different from Physical Business Address

Billing Address is the same as the Physical Business Address

Address Line

City

State

Postal Code

Country

Primary Point of Contact

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

Email Address

Each individual listed must have their own unique email address for system access.

Additional Contacts

Billing/ Accounting Point of Contact

The billing contact is responsible for batching and posting invoices in the healthAlign platform. This contact will also serve as the primary contact for provider payments. The billing contact receives all invoice and billing-related system notifications.

Add Billing Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access.

Referral Point of Contact

The referral contact is responsible for managing healthAlign service referrals. This contact receives all referral-related system notifications, including referral assignments and escalation notifications.

Add Referral Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access.

Credentialing Point of Contact

The billing contact is responsible for batching and posting invoices in the healthAlign platform. This contact will also serve as the primary contact for provider payments. The billing contact receives all invoice and billing-related system notifications.

Add Credentialing Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access.

Add another location

Additional location

National Provider Identifier (NPI) for this location:

Please indicate the NPI associated with the TIN/EIN provided

Physical Location

Address Line

City

State

Postal Code

Country

Billing Address

Billing Address is the same as the Physical Business Address

Address Line

City

State

Postal Code

Country

Primary Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Additional Contacts

Billing/ Accounting Point of Contact

Add Billing Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Referral Point of Contact

Add Referral Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Credentialing Point of Contact

Add Credentialing Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Add another location

Additional location

National Provider Identifier (NPI) for this location:

Please indicate the NPI associated with the TIN/EIN provided

Physical Location

Address Line

City

State

Postal Code

Country

Billing Address

Billing Address is the same as the Physical Business Address

Address Line

City

State

Postal Code

Country

Primary Point of Contact

Full Name

Phone Number

Email Address

Additional Contacts

Billing/ Accounting Point of Contact

Add Billing Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Referral Point of Contact

Add Referral Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Credentialing Point of Contact

Add Credentialing Point of Contact

Full Name

Phone Number

Email Address

Each individual listed must have their own unique email address for system access. Additional contacts can be added at a later date via our Credentialing Team at credentialing@thehelperbees.com

Add another location

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 required by the state)
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..."

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) - General Liability

4. Workman's Compensation

If Workman's Comp is not required per your state, select "Workers Comp not required”

Workers Comp not required

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:

RN Assessments	Personal Care Services	Companionship
Home Health Care	Homemaker Services	Other