1 New Contract Effective - April 1, 2013 US Rehab AS10231 Executive Resources Durable Medical Equipment/Services April 1, March 31, 2016 Supplier Information 1111 W. San Marnan Dr. Waterloo, IA Business Toll Free: (800) Business: (800) Website: Contract Highlights US Rehab is a National alliance for certified rehab technology equipment and accessibility providers. US Rehab has more than 380 members in over 1,200 locations nationwide. US Rehab promotes the uniqueness of the rehab technology industry. As a member benefits include vendor discount pricing and diverse product lines. US Rehab has many education opportunities including our Academy of Advanced Rehab Sciences which offers many rehab-related educational programs which consist of a 3 day Tech Training, and the Seating and Mobility Master Program. Members can also receive on-site training with Peggy Walker, RN, Ronda Buhrmester and Elizabeth Cole. US Rehab s goal is to offer a variety of ancillary programs that help members manage their businesses more effectively. Products Group purchasing on all complex rehab items, services, education programs, consulting, web design and hosting, marketing materials, managed care contracting, software solutions, other HME/DME/retail services. Eligible Facilities HME/DME - Retail Contract Access Geographic Service Area Available Nationwide Forms Required Membership application completed through US Rehab or VGM. See forms attached. Access Criteria VGM Membership Maximize Savings Identify yourself as an Amerinet member to capitalize on the VGM/US Rehab/Amerinet membership program. Payment Terms Non-contract monthly membership fees. Place An Order All product orders are placed directly with the US Rehab Participating Vendors. Contact: AS10231 US Rehab Frank Gillespie Page 1
2 Greg Packer Direct Cell: Delivery All orders placed will be shipped from the Participating Vendor. Price Or Discount Amerinet members receive a discounted US Rehab Membership at $100/month additional to VGM monthly membership dues. Product discount and pricing varies by product and service as defined in our Participating Vendor Contract Listing and our US Rehab Member Catalogs. Price Protection Contracted pricing exclusive to US Rehab Members. Freight Freight is defined under each Participating Vendor Contract. Minimum Order Minimum orders, account information and terms are defined under each Participating Vendor Contract. Supplier Diversity Not Applicable Failure to Supply/Perform Not Applicable Supplier Latex Information Not Applicable Medicare/Medicaid Disclosure Statement In accordance with the Medicare and Medicaid Patient and Program Protection Act of 1987 (P.L ), this is to notify you that payments, not to exceed three percent of all reported purchases made under the terms of this agreement, may be paid by the contract vendor or its authorized distributor(s) to Amerinet, Inc. to provide funding for continued program development and administration. Amerinet, through the organization with which you are affiliated, will disclose in writing to your facility, at least annually, the amount received from the above and/or its authorized distributor with respect to purchases made by or on behalf of your facility. Confidential Information All information herein listed is proprietary to Amerinet, Inc. Its use is strictly limited to the appropriate business purposes of the Amerinet Member facility to whom it has been provided, and may not be conveyed or provided in any way to any other party. AS10231 US Rehab Frank Gillespie Page 2
4 History of VGM Van G. Miller founded VGM & Associates Sept. 3, 1986, as a national buying group for independent home medical equipment providers. In the ensuing decades, it has expanded to include buying groups for high-tech rehab and respiratory providers, orthotic and prosthetic practitioners, the golf and private club industry and HME providers in Canada. The organization has grown to include 15 companies, the majority of which are related to the HME industry. Collectively, they re known as The VGM Group, Inc. VGM is the largest group of its kind in the HME industry. VGM s story really begins in 1978, when Van founded Miller Medical Service, an HME business that grew into a franchise operation with 26 locations in the Midwest. Because of its size, the company received healthy volume discounts from nearly all its vendors, enabling even the small franchisee to realize very good pricing. He sold his 50 percent ownership of Miller Medical in 1986, and founded VGM & Associates. In 2005, VGM implemented an ESOP, which is the centerpiece of the company s plan for succession and continuity. On June 3, 2008, VGM became a 100 percent employee-owned company.
6 U.S. Rehab is an organization for high-tech rehab providers. Acquired in 1997 by VGM, it has grown to an organization with more than 1,000 independently owned rehab member locations. Understanding the uniqueness of the rehab technology market, U.S. Rehab strives to assist members with services that will allow them to operate more efficiently and increase profitability. These services include excellent pricing from leading rehab equipment manufacturers, reimbursement and clinical advice from leading industry experts and top-notch educational programs, among other things. As a division of VGM, members can take advantage of a suite of products and services from the other 15 divisions within the organization. U.S. Rehab is proud that all members meet high-level admission standards and hold credentials from NRRTS and RESNA. A division of The VGM Group, Inc.
7 Elizabeth Cole Director of Clinical Rehab Services Carrie Etten Administrative Assistant Amanda Smith Marketing Coordinator Peggy Walker, RN Billing and Reimbursement Adviser Greg A. Packer Vice President
8 Member Communication U.S. Rehab communicates vital information to members via s. Information includes participating vendor promotions and rehab industry news. As a member, be sure to add to your address book to ensure you receive these communications. The U.S. Rehab website How to register for members-only online: 1. Go to and click on: Need a login? 2. Fill in the required information and create a password for your account. 3. Your registration will typically be approved within minutes, during business hours. 4. Sign-in using your address and password for members-only access to the website. Note: When registering for an account, be sure to check the box to begin receiving important updates. ListServ In keeping with the informational and communication needs of our membership, U.S. Rehab has established a ListServ. This ListServ makes it easier for members to communicate with one another. U.S. Rehab and members are able to quickly disseminate information and receive feedback and responses quickly by posting messages to this ListServ.
10 Members-only Publications U.S. Rehab periodically publishes special tools for members to use. These have included a Standardized Service Rate Guide, Financial Survey and Salary Survey. The goal of the surveys is to offer a variety of metrics that give you the chance to compare your company results to a sample of your peers. All data collected is from participating U.S. Rehab members. Participation in these projects is vital to get the most accurate information. The rate guide assists service managers by serving as a reference document for determining time allotment for standard service and repairs on most manual and power wheelchairs. All publications are available online at For members convenience, the standardized labor rate tables are available online in an Excel file format (with formulas included) for you to complete and print. A division of The VGM Group, Inc.
12 U.S. Rehab Technical Training The goal of U.S. Rehab s technical training is to create an elite group of Assistive Technology Technicians. The intensive, three-day sessions take place throughout the U.S., and are designed for service technicians who have worked with power rehab equipment for at least one year. Sessions are limited in size to ensure quality one-on-one training. Conducting the sessions, which cover everything from batteries to electronic troubleshooting, are U.S. Rehab Participating Vendors. Each vendor has assembled an open-book exam that features actual case studies. The timed replacement parts test covers all materials taught in the seminar, and focuses on efficiency and correct tool use. On the final afternoon, each attendee takes a comprehensive examination. Scores are used to provide certification recognition seals. Score Certification level 90 to 100 percent Red Star 80 to 90 percent White Star 70 to 80 percent Blue Star Upon successful completion of the training, you are able to receive additional discounts from participating vendors.
14 Educational Offerings Customized education U.S. Rehab offers you continuing education at your own location. Through our Custom Seminar Program, your staff and referrals have the opportunity to boost their professional knowledge locally. You choose the topic and the audience, and we bring the education to you. A wide array of topics are available, including characteristics of primary disability groups, client evaluation, assessment for assistive technology, funding and reimbursement, and an overview of other assistive technology for the ATP. cademy A d v a n c e d R e h a b E d u c a t i o n f U.S. Rehab s Academy of Advanced Rehab Education is your source for online learning. The academy offers an array of rehabrelated educational programs, including the Assistive Technology Training Program (ATTP) for individuals seeking the ATP Credential. These unique educational offerings allow you to learn at your own pace and in your own environment. By enrolling in U.S. Rehab s Academy of Advanced Rehab Education, you will receive a first-rate learning experience and education credits. Remember to check back with the academy often as we continue to develop new courses tailored to meet your needs. The academy is available at:
16 Billing and Reimbursement Help Peggy Walker, RN, serves as U.S. Rehab s billing and reimbursement adviser. She has special rehab expertise, and is available to help answer questions about Medicare requirements and billing for seating systems and high-tech rehab products. A frequent speaker at regional and national events, Peggy is also available to conduct inservices at member facilities. While working for HHE Consulting in South Carolina, she implemented a pre-screening program for specialty and rehab wheelchairs. Peggy also conducts a traveling road show. This hands-on workshop takes you through the Medicare billing process from start to finish. Several shows are held each year in various locations across the United States Clinical Rehab Services Elizabeth Cole has been involved for the past 25 years in many aspects of assistive technology. As a physical therapist, Elizabeth practiced in neuro-rehabilitation and ran a seating and mobility clinic. She then joined a major DME manufacturer, working first in seating and mobility sales and later as director of education, responsible for development and instruction of education programs in seating and mobility prescription. She has also used her industry experiences as a consultant, providing clinical and reimbursement consulting for HME and assistive technology. She has been published in national industry journals, is a member of the RESNA Board of Directors, a Friend of NRRTS and a member of the Clinician s Task Force
18 U.S. Rehab FAQs Is there an advantage to U.S. Rehab membership in addition to my VGM membership? Absolutely! There are several differences that distinguish U.S. Rehab membership from VGM. You will have access to more than 20 vendor contracts that are not offered to VGM Members. In addition, you receive special pricing from certain VGM Group Vendors. U.S. Rehab is dedicated to keeping its members in the know when it comes to high-end rehab related industry news and updates through communication and exclusive consultants. This information is only distributed to members. How do I enroll in U.S. Rehab? It s simple to join. You simply complete the membership application and participating forms and fax them in or complete online at our website. We will process your application and assign you a membership number that starts with the letter U. Why do I have to fill out forms with my application? We work to ensure you have the best pricing available. In order to ensure participating vendors have your account connected to the U.S. Rehab contract, we require these forms. What happens after you assign us a member number? U.S. Rehab notifies all of our participating vendors that you have joined the group. You will now be able to sign up for members-only access to our website. You will also receive a complete participating vendor catalog in the mail.
19 Does membership in U.S. Rehab automatically establish accounts with each of the vendors? No, it does not. However, as part of the contract process and your affiliation with U.S. Rehab, we have made establishing an account with participating vendors less strenuous. What is the best way for the staff members to keep updated on U.S. Rehab vendors? The most current information, pricing details and current promotions can be found on our website (www.usrehab.com), under the members-only section. You should also register to receive our communications, as we send any time-sensitive materials with this method. To ensure you receive these s, add com to your address book. How do I know where upcoming U.S. Rehab classes are going to be? U.S. Rehab recently launched a new website with a calendar feature. By going to the calendar, you can view upcoming events and a link to registration. Does U.S. Rehab offer the ATP exam? We do not. The ATP exam is only given by RESNA, however, U.S. Rehab has several tools to assist you in your exam preparation. As a member, do you help me get a voice in the industry? Of course! We encourage all members to stay active with their state associations and boards and contact with your elected officials. U.S. Rehab is represented on several rehab boards such as NCART, CRMC, RESNA, NRRTS and AA Homecare.
20 For more information about joining U.S. Rehab, call us at or visit our website, A division of The VGM Group, Inc.
22 THE VGM GROUP (Office use only) Member #: Dues: Member Service Rep: Start Date: MemberApplication M E M B E R S E RV I C E O R G A N I Z AT I O N Current VGM Member Number: Please print clearly and complete all fields: Legal Company Name: DBA: Mailing Address: City: State: ZIP code: Phone: Fax: 24-hr fax? Yes No Owner's Name(s): Store Contact (if different than owner): Medicare#: Medicaid#: Federal Tax ID#: NPI#: Do you have any branch stores? Yes No If yes, total number of branch stores: *Please include additional branch locations on back page List your top 5 product vendors and approx. annual volume with each: Accounts payable contact person at your company: Does your company have a website? Yes No If yes, the address: Is your company accredited? Yes No If yes, with whom? ACHC CHAPS HQAA JCAHO Other: Credentialed employees: (check all that apply) CRTS ATP PT OT What products or services do you provide? (Please check all that apply) Wheelchairs Ramps (built) ECUs (environmental control units) Custom rehab Patient lifts Wheelchair/scooter lifts Ramps (rental) Patient supports Vehicle modifications
23 Additional Branch Locations Branch Name: Store Contact: Branch Address: City: State: ZIP Code: Phone: Fax: Medicare#: Medicaid#: Federal Tax ID#: Branch Name: Store Contact: Branch Address: City: State: ZIP Code: Phone: Fax: Medicare#: Medicaid#: Federal Tax ID#: Branch Name: Store Contact: Branch Address: City: State: ZIP Code: Phone: Fax: Medicare#: Medicaid#: Federal Tax ID#: *Please include additional branch locations on a separate sheet Communication is key! At VGM, we send out timely s on the following topics: general announcements, legislative updates, vendor promotions, national competitive bidding updates and regulatory updates. Who at your office should receive information on these topics? Please log on to to sign up for a user name and password in the Members-Only Area of the website and check which s you would like to receive. I understand that my U.S. Rehab network dues will be an additional montly fee of $150 per month and that I must stay current (60 days) or will be subject to cancellation. This application is submitted in connection with business and commercial financing and NOT for personal, family or household purposes. You warrant the information on or relating to this application (the data ) is true and complete, and you will notify us of any material change therein. You consent to and authorize (i) us and our agents to obtain commercial and consumer credit reports, make other inquiries and investigate references and data, and (ii) anybody contacted by us or our agents to release credit and financial information. We comply with Section 326 of the USA Patriot Act, which mandates that we verify certain information about you while processing your account application. You also authorize us to offset any sums due from any of our affiliated companies, including but not limited to HOMELINK, against any unpaid sums you owe us, our affiliated companies, or VGM Financial Services, without notice. You hereby waive any and all claims for payment of any offset made and also release HOMELINK from any and all claims or liability for said payment. I understand that VGM enters into contracts with participating vendors to obtain discounted pricing for VGM Members, and that such vendors may pay a fee to VGM not exceeding 3 percent of the price of goods I purchase from the vendor. Any cancellations are required in writing. EQUAL CREDIT OPPORTUNITY ACT. If your application for business credit is denied, you have the right to a written statement of the specific reasons for the denial. To obtain the statement, please contact our customer service representative, within 60 days from the date you are notified of our decision. We will send you a written statement of reasons for the denial within 30 days of receiving your request for the statement. NOTICE: The federal Equal Credit Opportunity Act prohibits creditors from discriminating against credit applicants on the basis of race, color, religion, national origin, sex, marital status, age (provided the applicant has the capacity to enter into a binding contract); because all or part of the applicant s income derives from any public assistance program; or because the applicant has in good faith exercised any right under the Consumer Credit Protection Act. The federal agency that administers compliance with this law concerning this creditor is the Office of the Comptroller of the Currency, Customer Assistance Group, 1301 McKinney Street, Suite 3710, Houston, Texas By signing below, the undersigned principal or guarantor of the applicant hereby authorizes VGM to obtain one or more credit profiles on him, her and/or the applicant from a credit reporting agency for use in connection with (a) the transaction currently contemplated, (b) the extension of credit, (c) any subsequent updates, renewals, or extensions of the transaction currently contemplated or credit, and (d) review or collection of any resulting accounts. In addition, the undersigned hereby authorizes any bank, financial institution or trade reference listed herein to release usual and customary business or personal credit information to VGM. A copy of this signed authorization shall be deemed an original for all purposes. Owner s Signature: U.S. Rehab Associate: Please bookmark the following website for reference: Date: Date: U.S. Rehab Member Application
24 VGM PARTICIPATING VENDORS LIST Please mark the Vendors you purchase from and list your account numbers. This allows us to make sure the Vendor tags your account for the proper U.S. Rehab discounts. U.S. REHAB EXCLUSIVE PARTICIPATING VENDORS AbleNet Bodypoint Comfort Company Harmar Innovation In Motion Innovative Concepts Ki Mobility Leisure Lift LMN Builder Moen Home Care Motion Concepts Permobil PDG Product Design Group PRM (Signature 2000) Raz Designs Richardson Products Rifton Equipment Roho The Aftermarket Group Therafin Revised 04/16/2013 EH
25 Date Member# VGM U.S. Rehab Nationwide Respiratory NOTICE OF GROUP PURCHASING DECLARATION FORM has entered into a Group Purchasing Organization (GPO) Agreement with VGM & Associates, U.S. Rehab, Nationwide Respiratory) (VGM ). If you are currently crediting our purchases to another GPO, we wish to change our affiliation with that GPO for all purchases. Furthermore, we agree to comply with the GPO Purchasing Agreement between VGM and the Supplier. Declaration On behalf of and its legal affiliates purchasing your products, the undersigned hereby agrees to and certifies the following: Effective immediately, our company hereby declares that our GPO of record be VGM & Associates and/or U.S. Rehab and/or Nationwide Respiratory (VGM) for the purchase of your products. The undersigned has full power and authority to execute this Certification. Signature: Date: Print Name: Print Title:
Guidelines for completing the Orscheln VISA Credit Card Business Application The guidelines listed below are designed to help you assist the business in submitting a complete business application. Following
General Information 20 East Bayard Street, PO Box 111 Seneca Falls, NY 13148 BUSINESS LOAN APPLICATION Business Taxpayer ID #: Business Address: Telephone #: Cell Phone #: E-mail contact: Fax #: Nature
Customer: Thank you for choosing to do business with S. T. Wooten Corporation. We are committed to providing you, our valued prospective or existing customer, with the highest level of satisfaction possible.
Business Credit Application (Please type or print all information. Answers requiring additional space submitted on separate pages.) Firm Name: Firm Address: Firm Telephone: Firm Web Site URL: Email: EIN/Tax
Visa Business Credit Card Visa Business Rewards Credit Card Card Center, P.O. Box 410436, Kansas City, MO 64141-0436 Branch ID no. Associate ID No. Agent # - BBW 0240 COMPANY INFORMATION Company Name Street
Dealer Application Checklist: Completed Dealer Authorization Form o Each owner/principle must sign and date form Completed Credit Application o Signed and dated application with all owners and principal
Commercial Loan Application loans, credit lines, checking whatever it takes... plus someone who makes your business, their business. Loan Requested Term Loan or Real Estate Loan New/Increase Line of Credit
BUSINESS LOAN APPLICATION Each owner, shareholder, partner or member owning 20 percent or more interest in the business must sign a personal guaranty. A minimum of 1 guarantor is required regardless of
VALUEBANK TEXAS - COMMERCIAL LOAN APPLICATION Important Application Information: Federal law requires financial institutions to obtain sufficient information to verify your identity. You may be asked several
BUSINESS INFORMATION Must be completed in its entirety SBA LOAN APPLICATION Company Name DBA or Franchise (if applicable) Phone Fax E-Mail Street Suite # Website City State Zip Code Date Company Founded
US short form ADI New Account Required Documentation Required Documentation for a New Business Account with ADI and Credit Agreement Thank you for your interest in establishing a business credit account
Small Business Environmental Loan Program Application Arkansas Department of Environmental Quality Public Outreach & Assistance Division Business Assistance Program 5301 Northshore Drive North Little Rock,
Thank you for considering a business loan from Cambridge State Bank. In order for us to better understand your business, please take a few moments to describe your company, your owner(s), your customers
New Contract Effective - March 1, 2011 Information Services Consulting Services, Outsourcing March 1, 2011 - February 28, 2014 Supplier Information 723 E. Locust Ave Ste. 117 Fresno, CA 93720 Business:
CITADEL BUSI ESS ACCOU T / BUSI ESS LOA APPLICATIO Part 1 - Business Information Account Number Date Business Established: State of Incorporation/ Organization: Type of Entity: Individual/ Sole Proprietorship
BUSINESS LOAN PACKAGE First Federal Bank of Florida BUSINESS CREDIT APPLICATION INFORMATION ABOUT THE BUSINESS: Legal Business Name Physical Address City State Zip Type of Organization: Sole Proprietorship
COMMERCIAL LOAN APPLICATION Thank you for considering Enterprise National Bank N.J. for your commercial loan needs. This application along with other information you supply will provide us with the information
Rehab Net of Arkansas Provider Application Discipline P.T. O.T. S.L.P. (1) Business Name Physical Address FACILITY DATA Phone Fax (2) Billing Address Phone Fax (3) Mailing Address (4) Owner/Contact Person
Thank you for your interest in pursuing financing with Valley National Bank. In order to begin the analysis of your credit request, please complete the following: Commercial Loan Application Personal Financial
WEDCO Wentworth Economic Development Corporation, Inc. 7 Center Street, PO Box 641, Wolfeboro, NH 03894 Phone: 569-4216 Fax: 569-3317 Website: www.wedco NH.org Small Business Loan Application All information
HOSPITAL-ANCILLARY-CLINIC PROVIDER CREDENTIALING APPLICATION INSTRUCTIONS: In order to be considered complete: 1. All information must be legible. Please print or type all information 2. Application must
T hank you for asking about the City of Warren Revolving Loan Funds. We are pleased that you are taking the initiative to open or expand your business. Owning a business takes dedication, hard work and
Member FDIC Business Loan Application To expedite processing of your request, please ensure that this application has been completely filled out and that any additional documents are attached. Notice to
Dear Borrower: 90 W. BRAKER LANE BLDG 3, STE 00 AUSTIN, TX. 78758 P 52 835 6600 F 52 835 664 Thank you for considering Business Bank of Texas, N.A. for your business credit needs. We are committed to helping
Application Package Completeness Checklist All Businesses Business Loan Application dated within the last 30 days Schedule of Business Debt for each business entity participating in the loan Personal Financial
Membership Print Membership Agreement CASH PAYMENTS ARE NOT ACCEPTED CLIENT TERM AGREEMENT This CLIENT TERM AGREEMENT ( Agreement ) is made and effective upon clicking submit by and between Cheap Delete
COMMERCIAL/BUSINESS LOAN APPLICATION PACKAGE CONTENTS: Member Business Loan Application Authorization to Obtain Credit Information Financial Statement Schedule of Business Debt REAL ESTATE & COMMERCIAL
CITADEL BUSI ESS ACCOU T / BUSI ESS LOA APPLICATIO Part 1 - Business Information Account Number Date Business Established: State of Incorporation/ Organization: Type of Entity: Individual/ Sole Proprietorship
SBA LOAN APPLICATION This checklist has been provided to assist you through the process of gathering the necessary information for the initial evaluation of your loan request. Complete information will
Aircraft Finance Capital The following guidelines are provided to facilitate approval review of your finance request. These items are guidelines only; additional items may be required pending actual credit
BUSINESS CREDIT APPLICATION INFORMATION ABOUT THE BUSINESS: Legal Business Name Physical Address City State Zip Type of Organization: Sole Proprietorship Partnership C-Corp S-Corp LLC Other Tax Identification
The Florist Federal Credit Union BUSINESS LOAN APPLICATION I. GENERAL INFORMATION Applicants Name / Borrower (individual business owner or business name): Tax ID Number: Mailing Address: Contact Person:
NAME HOME PHONE WORK PHONE CELL PHONE BIRTH DATE MALE PATIENT INFORMATION FEMALE SOCIAL SECURITY # EMAIL REFERRING PHYSICIAN PRIMARY PHYSICIAN NAME PHONE # AGE PARENT/LEGAL GUARDIAN PAYMENT RESPONSIBILITY
Greetings from the Lake Region Bank commercial lending staff! To speed up the processing of your application, please bring the below information in with your application appointment: 1. Complete as much
BUSINESS LOAN APPLICATION SECTION A: TYPE OF CREDIT APPLYING FOR Type of Loan Amount Requested Business Line of Credit Primary Purpose of this Loan(s): Equipment Term Loan - Length: Letter of Credit Commercial
ORDERING PROCEDURE for Asept Drainage Kit 1. All patients must submit completed forms listed below to (AMS): Letter of Medical Necessity (To be completed by Physician) Patient Information form Assignment
Can t Get 30 Day Credit Terms With Your Suppliers? Get Business Credit Assurance. WWW.NET30CREDIT.COM How Credit Assurance Works. Once your credit is approved, we can issue credit assurance to your qualified
FLORIDA BLUE HOSPITAL, ANCILLARY FACILITY AND SUPPLIER BUSINESS APPLICATION Florida Blue Provider Number: Facility Name: Legal Name (if different from above): Facility Physical Address: City: State: Zip
Burke Center Request for Proposal For a Defined Contribution Retirement Plan Burke Center is a Community Mental Health and Mental Retardation Center authorized under Chapter 534 of the Texas Health and
SCHERTZ BANK & TRUST COMMERCIAL LOAN APPLICATION LOAN REQUEST Business Term loan Commercial Line of Credit Commercial Real Estate Amount Requested $ Proposed Collateral and Value: Term/Month Business Legal
Phone: 831-708-2919 Fax: 831-708-2937 PATIENT REGISTRATION FORM Who may we thank for referring you to us? Name (First, Mid Int. Last) Address City State Zip Code Home Phone w/ area code Email Cell Phone
Electricity and Natural Gas Supply Services AUTHORIZATION & APPLICATION FORM ELECTRIC AND NATURAL GAS BILLING, PAYMENT HISTORY, ACCOUNT SERVICE DATA, AND CREDIT DATA SUPPIER AUTHORIZATION Customer Location:
Comprehensive Geriatric Medicine d/b/a Doctors on Call Provider Employment Application Thank you for your interest in employment at Comprehensive Geriatric Medicine d/b/a Doctors on Call. As a leader in
Commercial Use Application See what fast and easy access to credit can do for you. As every independent business owner knows, everything turns on cash flow. That s why John Deere Credit makes it easy for
EPS EFT Enrollment Authorization Agreement Optum is improving service to you by replacing paper checks and Explanation of Benefits (EOBs) with the Optum EPS solution. Get a head start by enrolling today!
Deerfield Insurance Company Evanston Insurance Company Essex Insurance Company Markel American Insurance Company Markel Insurance Company Associated International Insurance Company APPLICATION FOR SPECIFIED
APPLICATION AND AGREEMENT FOR Subsidized CHILD CARE DISTRIBUTION SERVCIES THIS AGREEMENT ("Agreement") between Fidelity Information Services, LLC. an Arkansas limited liability company located at 601 Riverside
Applicant s Name 322 East Main Avenue Bismarck, ND 58501 (701) 250-3000 Lender Please tell us about yourself and co-applicant, if applicable Co-Applicant s Name Home Equity Line of Credit Application Home
Application for Employment GENERAL INFORMATION (Please Print) Name: Telephone No.: LAST FIRST MIDDLE Email Address: Present Address: Position Desired: STREET CITY STATE ZIP Pay Desired: If hired, can you
Special payment rules for items furnished by DMEPOS suppliers and issuance of DMEPOS supplier billing privileges. All Medicare DMEPOS suppliers must be in compliance with these Supplier Standards in order
Wesley Village Campus Tunkhannock Campus APPLICATION FOR RESIDENCY Applicant s Name Residence: No. and Street P.O. Box No. City State Zip Code Telephone No. Social Security No. Birth Date Sex Marital Status
COMMONWEALTH of VIRGINIA Department of Medical Assistance Services HCBCS - Consumer Directed Service Coordination VIRGINIA MEDICAID PROVIDER ENROLLMENT PACKAGE Thank you for your interest in becoming a
checklist. INSTRUCTIONS Please complete this application and provide the information requested on the application checklist. Confirmation of receipt of a request will be made within approximately 5 business
Medicaid Purchasing Administration (MPA) Diabetes Education Program Billing Instructions ProviderOne Readiness Edition About This Publication This publication supersedes all previous Department/MPA Diabetes
DELTA DENTAL PPO+Premier Participating Independent Dental Hygienist Agreement THIS AGREEMENT, made and entered into this day of, 20 by and between Colorado Dental Service, Inc. d/b/a Delta Dental of Colorado,
DALLAS COUNTY COMMUNITY COLLEGE DISTRICT REQUEST FOR QUALIFICATIONS NUMBER 12006 EXECUTIVE SEARCH COMPANY for SELECTION OF CHANCELLOR PROPOSALS DUE BY 2:00 P.M. APRIL 18, 2013 INDEX CONTENTS PAGE NUMBER
Ohio Department of Job and Family Services Ohio Health Plans Provider Enrollment Application/Time Limited Agreement for Individual Practitioners Submit completed signed application/agreement with required
STATE OF TENNESSEE DEPARTMENT OF INTELLECTUAL AND DEVELOPMENTAL DISABILITIES Credentialing Application for Dental Services and/or Anesthesia Service Provider qualification specified in the Home and Community
For CDA use only: application first received: Project ID#: Dear Homeowner: With funding and Programs available, NOW is a great time to have those needed home repairs done! Thank you for your interest in
Provider Selection Criteria for PreferredOne Participating Home Health Care Agencies General Criteria 1. Practitioner must serve a specialty and/or geographic need for the good of the PreferredOne product
LENDING CHECKLIST Below you will find a list of documentation that our lenders generally require. Please gather this documentation and send it back to us along with your completed application and disclosures:
Lending. Supporting. Inspiring. Are you eligible for an ACCION Chicago small business loan? Y/ N Are you looking for a loan between 200 and 15,000 for your start-up business (less than 6 months of revenue
Application for Commercial Real Estate Loan Branch: Customer/Borrower Legal Name: Date Physical Street Address: City State CA Fed Tax ID No. Social Security Zip Telephone No. Fax No. Individual Corporation
REFERENCE # SUBJECT: CHARITY AND UNCOMPENSATED CARE 1 of 13 DEPARTMENT: BUSINESS OFFICE REVISED: 10/2012 CHARITY AND UNCOMPENSATED CARE Purpose To provide definition of health care assistance to eligible
DELTA DENTAL PPO PARTICIPATING DENTIST AGREEMENT THIS AGREEMENT, made and entered into this day of, 20 by and between Colorado Dental Service, Inc. d/b/a Delta Dental of Colorado, as first party, hereinafter
POLICY AND GUIDELINES DIVISION: Business Management TOMAH MEMORIAL HOSPITAL, INC. ORIGINATION DATE: 11/01/86 TOMAH, WI 54660 PAGE: 1 of 6 Approved By: Author Administrative Team Leader Board of Directors
TITLE 18 INSURANCE DELAWARE ADMINISTRATIVE CODE 1 900 Consumer Rights 906 Use of Credit Information [Formerly Regulation 87] 1.0 Authority This regulation is adopted by the Commissioner pursuant to the
HOW TO COMPLETE THIS FORM PRODUCTS LIABILITY INSURANCE APPLICATION To complete this form, you must be a principal, partner, or director of the applicant firm and should make all the necessary inquiries
Maryland Capital Enterprises, Inc. PO Box 213, Salisbury, MD 21803 Office: (410)546-1900 / Fax: (410)546-9718 Business Loan Application For Existing Businesses Thank you for your interest in Maryland Capital
Missouri Assistive Technology 1501 NW Jefferson Street Blue Springs, MO 64015 Voice: 800-647-8557 (in-state only) or 816-655-6700 TTY: 800-647-8558 (in-state only) or 816-655-6711 www.at.mo.gov Application
WHAT DO I NEED TO SUBMIT IN ORDER TO BE CONSIDERED FOR A LOAN? In order to properly review your loan request, please submit the following items: 1. Attached Business Loan Application 2. 2012 and 2013 Federal
Performance and Payment Bonds Submission Requirements 1) Request for Performance and Payment Bonds. (Forms attached for your convenience, please return only with a Performance and or Payment Bond Request.
The Lakeland Companies are committed to protecting your privacy. This statement details the steps we take to protect your personal information when you visit our websites. It describes the personal information
The same high standards that go into making a Jackʼs New Yorker Deli sandwich apply to every aspect of our business system. Here's what you receive with a Jackʼs New Yorker Deli Franchise: Site Selection
DISCLAIMER, TERMS & CONDITIONS OF USE Welcome to Universal Devices, Inc.'s online website. By accessing and using this website, you acknowledge that you have read, agree to, and are aware of the following
Authorized Subscribers Obtaining a Digital Certificate following receipt of your Authorized Subscriber Membership number Instructions: April, 2013 Following the acceptance of your application to become
Children with Special Health Care Needs (CSHCN) Services Program Expedited Enrollment Application Rev. VII Introduction Dear Health-care Professional: Thank you for your interest in becoming a Children
SD MEDICAID PROVIDER AGREEMENT The SD Medicaid Provider Agreement, hereinafter called Agreement, is executed by an eligible provider who desires to be a participating provider in the South Dakota Medicaid
Sunrise Loan Fund Application Form Instructions For Application Form Sections I, II, III. Please provide the information requested. "You" refers to the proprietor, general partner, or corporate officer
Member FDIC S.B.A. LOAN APPLICATION As the first Lender in the Dallas/Fort Worth area to achieve Preferred Lending Status from the U.S. Small Business Administration, our SBA Department is pleased to review
Mortgage Loan Application Package REFINANCING ONLY Section 1: Application documents For loans to refinance a residential property, the following is required to be obtained with the application: Residential
Your consent to our cookies if you continue to use this website.