Pediatric Add-On Agency Information Form

Pediatric Add-On Agency Information Form

Agency Name

Agency or Corporation Name

Agency D/B/A (if applicable)

Registered "Doing Business As" or 'Assumed" Name for your corporation

Agency Phone Number:

Agency Fax Number:

Agency Address

Street Address

Address continued

City

State

Zip

Agency Services

Service Area (Counties list & Milage Radius)

See Policy AO.016 - Provide list of Counties and milage radius from the agency that you plan to serve (Example - Ant County, Bee County, Polk County, Orange County with a 80 mile radius from the Agency Office)

Office Hours

Example - Mon to Friday 8.00 am to 5.00 pm

Charge Rates Per Visit (Non - Medicare/Insurance)

Per Visit Charge (Skilled Nursing)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source.

Per Visit Charge (Home Health Aide)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source

Per Visit Charge (Physical Therapy)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source)

Per Visit Charge (Occupational Therapy)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source

Per Visit Charge (Speech Therapy)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source)

Per Visit Charge (Medical Social Worker)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source

Per Visit Charge (IV Therapy)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source

Per Visit Charge (Home Dialysis)

(Optional) information on your per visit charge rates for services not covered by Insurance, Medicaid or any other Payment source

Agency Managerial Roles

Administrator Name

Provide the full name and any letters after the name (EXAMPLE R.N)

Alternate Administrator Name

Provide the full name and any letters after the name (EXAMPLE R.N)

Director Of Nurses Name or Supervisor Name

(Can be same person as Administrator if Qualified )DON - Director Of Nurses or Licensed Therapy Services only - Provide any letters after the name (EXAMPLE R.N or P.T)

Privacy Officer Name

Privacy Officer - usually same as Administrator

Any Additional Information

If you have any further information that you would like to send us(Place your text here)

(Optional) Upload your Logo Image for forms

Our Graphic Design Team can create a basic logo or re-create your existing logo Free Of Charge. Please fill out the Logo Request Form if needed. When you get the finished logo and you have approved it, then come back here and upload it.

Your E-mail (for us to contact you)

(for us to contact you)

Order# (this was emailed to you)

Need assistance with this form?