Application for Medical Equipment and Services Providers

Corporate Provider Information (RED indicates required field)

Federal Tax ID# NPI # License #
Medicare # Medicaid #  
Company Name  
DBA  
Address Suite  
City State Zip
Telephone Fax Company Website
Organizational Structure  
Organzation Inception Date State of Incorporation MED Membership #
Multiple Facilities If Yes, is there a centralized intake?
Intake Main Phone Main Fax After Hrs Phone
Hours of Operation TO Days Of Operation

In-Network Payer Status

Select all states you have coverage in and click "Show Payers".

Corporate Products and Services Offering

Please identify the services you provide (NU New, RR Rental)

Corporate Contact Information

President/CEO Phone Email
GOMEDEDGE Administrator Phone Email
Operations Manager Phone Email
Billing Manager Phone Email

Corporate Remit and Billing Information

Address Suite  
City State Zip
Telephone Fax Email

Facility Location 1

NOTE: Zip codes can be entered individually with a comma delimiter (#####, #####,) or as a range (#####-#####,)

Location Name(1)
Address City
State Zip Code
GOMEDEDGE Referral Admin Email
Zip Codes Served
Notes

Facility Location 2

Location Name(2)
Address City
State Zip Code
GOMEDEDGE Referral Admin Email
Zip Codes Served
Notes

Facility Location 3

Location Name(3)
Address City
State Zip Code
GOMEDEDGE Referral Admin Email
Zip Codes Served
Notes

Liability Insurance Information

Liability Insurance Carrier  
Policy Number Expiration Date
Liability Coverage per occurrence ($M)  
Liability Coverage general aggregate ($M) Liability Coverage professional ($M)

Corporate Accreditation & Staff Certification

Accreditation Yrs Accredited Expiration Date Accreditation Yrs Accredited Expiration Date

Certification # of Staff Certification # of Staff

Trade References

Company Yrs associated
Contact Telephone
Address City
State Zip

Company Yrs associated
Contact Telephone
Address City
State Zip

Corporate Compliance

Does your organization have a formal quality assurance program?
Does your organization have a formal infection control plan?
Does your organization have policies and procedures for patient grievance and resolution?
Are the credentials, certifications and/or licenses of personnel involved in the care and/or treatment of patients verified by your organization prior to employment or contract?
Are the credentials, certifications and/or licenses of personnel involved in the care and/or treatment of patients re-verified by your organization at least every three years or at expiration?
Are you able to provide / deliver same day urgent services, 24 hours a day / 7 days a week?
Do you run background checks on all personnel (employed / contracted) who enter a patient’s home (if applicable)?

Corporate History

Have you had any Medicare / Medicaid sanctions within the last 10 years?
Has your organization or any member of your staff ever been expelled, excluded, or suspended from any federal program or from service reimbursement under Medicare or Medicaid?
Are there any actions contemplated or pending against this organization by any government agency, professional group, institution, or other entity?
Has your organization’s professional liability coverage ever been restricted, limited, denied or cancelled?
Has any insurance carrier ever made an out-of-court settlement or paid a judgment on a professional liability claim on your organization’s behalf?
At present or during the last five years, has this organization been part of any legal proceedings?
Do you have any litigation pending?
Have there ever been any actions against your organization’s license, accreditation, certifications or permits or the license of any member of your staff, including restrictions, limitations, denial, suspension, revocation or cancellation?
Has your organization or any member of your staff ever been convicted of or pleaded no contest to a felony or other criminal offense, including, without limitation, a criminal offense related to Medicare, Medicaid, or any other federal program?
Has your organization ever lost its accreditation status?

Our Company Would Like to Participate in these Networks

Work Comp Network Partners Patient Supplies (Q2 2009 Launch)
Support Surfaces Commercial Sleep PPO for Transportation
Managed Care Network (Q2 2009 Launch) Complex Rehab