Community care hub provider application

Application Date*

Main Contact Name*

First Last

Phone*

Email*

Agency Name*

Website*

Tax ID*

Is your organization tax-exempt under section 501(c)(3) of the Internal Revenue Code?*

Yes

What type of service provider is your organization (including possessing all necessary documentation, licenses, and certifications required to legally perform these services)? Please check all that apply.*

Enhanced Care Management (ECM) and Care Coordination

Home Care Organization

Community Health Worker (CHW)

Care Transitions

Food/nutrition focused organization and meal/food provider

Housing Navigation

Housing Deposits

Housing Tenancy and Sustaining Services

Other services not listed here

Other services not listed here, please specify:

Address*

Street Address Address Line 2 City State ZIP Code

How did you hear about us?*

If colleague/organization, please specify

If health plan, please specify

If other, please specify

Provide a brief description of your organization's background, experience and qualifications*

Days and Hours of Operation*

Populations Served/Focus*

If other, please specify populations served/focus

Ages Served*

Individuals served per year*

List current services offered*

Check off all counties served*

*=Primary area of coverage needed

NPI#

# of Staff*

Number of years providing service*

For Enhanced Care Management (ECM), are your staff trained in planning?*

Yes

Do you provide Paramedical Services?*

Yes

For Private Duty (personal care, homemaker and respite) services, are you a licensed Home Care Organization?*

Yes

N/A

If yes, what is your HCO license number?

For Private Duty services, do you use an Electronic Visit Verification (EVV)?*

Yes

What is the name of your EVV system?

Bilingual Staff*

Yes

Languages Served*

List current Health Plan Contracts if applicable

Please select Community Care Hub Contracted Services interested in providing*

If other services not listed here, please specify

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