Service Provider Network Application

Provider Information

Legal Name of Company/Organization:

Type of Company/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 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

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

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?

YesNo

Is the credentialing point of contact different from primary?

YesNo

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

Email Address

Phone Number

Alt Phone Number

Credentialing 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

Email Address

Phone Number

Alt Phone Number

Does your company maintain policies and/or 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:
Employee training:

Please provide details and/or upload pertinent documentation

State license (If required by the state)
W-9
COI (If you are not required to have these insurances per your state, please respond with "not required for our agency.”)

a. General Liability

b. Workers Compensation

c. Employer Liability

d. Crime Liability

e. Auto Liability

f. Privacy Liability

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

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.”
Add additional files by selecting "Upload additional..." below

Not required by the state

Provide additional comments if needed:

I attest that the information provided on this 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:

Lawn Care	Pest Control	Home Repair
Food Delivery	Transportation	Meal Prep/Meal Delivery
Errands	Home Modification	Homemaker services
Other