Early Childhood Department Procedural Guidelines for Independent Contractors

Transcription

1 Early Childhood Department Procedural Guidelines for Independent Contractors A. Independent Contractors (Therapists): Please contact Developmental Pathways Early Childhood Department Representative, Nicole Spiering: for application materials and procedural information to enable you to provide EI services to our birth to age three children. You will need to Complete And Submit The Following Steps BEFORE Providing Any Services: (If services are rendered prior to these steps being taken, Developmental Pathways is not obligated to pay for those services.) 1. Application Fee: $ Please make check payable to Developmental Pathways (this includes fees for the background check, administrative expenses, etc. 2. Pre-Qualifications of Vendors Packet - Complete as a Business or Individual 3. Background Check, - Forms titled Release Authorization and Disclosure to Employment Applicant Regarding Procurement of a Consumer Report (these allow us to check the states in which you have lived) 4. Proof of Licensor (ie-trade name, Business License, Therapist Certification/License, etc.) A Trade Name is required for all contractors except for Therapists. You must register a Trade Name at 1375 Sherman St., Room 160, between the hours of 8-4:30 p.m. Please, send proof with packet 5. Current Resume Include education and experience and also specialties in area(s) of expertise. 7. Proof of Business Liability Insurance - Independent Contractors must have Professional Business Liability Insurance. 8. Copy of Colorado Driver s License, Social Security Card (or Passport) You will required to bring the original documents in when you attend Orientation Training. 9. W9 - form to allow you to bill Developmental Pathways. Original Copies must be Mailed or Delivered to Attention: Nicole Spiering, Program Manager Developmental Pathways 325 Inverness Drive South Englewood, CO The approval process may take up to one month or longer AFTER THE PACKET IS COMPLETED, Prior to Beginning Services After completed packets are reviewed and references are checked, etc., an ECD Representative will contact you regarding the status of your packet PRIOR to starting services. An appointment will be set up to receive your EI Service Provider Packet and Orientation information. This will also be a time to answer any additional questions you may have. The packet includes essential information regarding our model of EI service provision under Part C, Colorado Department of Education and Division of Developmental Disabilities, as well as information on DP processes, procedures, billing, etc. An Independent Contractor Contract will be signed before you are allowed to bill for services. A PAR (Prior Authorization) in the form of a Supports and Services page from the IFSP for each child with whom you will provide services, will need to be signed by a DP Manager PRIOR to starting services. A copy of the signed S&S will be ed to you. Payment is accomplished by monthly invoice after the service is provided. **Developmental Pathways will randomly survey Independent Contractor Records

2 Service Providers/ Independent Contactors and or Agencies Providing Services to Children and Families This information is intended for use in evaluating your qualifications to provide services as an Early Intervention Independent Contractor. Please answer all appropriate questions completely and accurately. False or misleading statements on this form are grounds for terminating the qualification process or, if discovered after contracting, immediately terminating the contract. All qualified contractors will receive consideration without discrimination based on race, color, religion, veteran or marital status, national origin, sex, presence of a mental or physical challenge (or condition) or sexual orientation. THE FOLLOWING IS TO BE COMPLETED BY THE OWNER/CEO OF THE COMPANY NAME (of Company or Individual) (or you as an Individual if you do not have a company/business) OWNER/CEO (if a company) ADDRESS: CITY: STATE ZIP PHONE: FAX: ADDRESS TYPE OF ENTITY: Proprietorship Partnership Corporation Other/Individual NUMBER OF EMPLOYEES: One (self) 2 to to More than 50 INCORPORATION DATE: NUMBER OF LOCATIONS: BANK REFERENCE: Yes No Have you ever been convicted of a felony? If so, please attach information including the date(s), city/state, and change(s). Yes No Have you served time or received deferred sentence for any offense? If so, please attach information including the date(s), city/state, and change(s). Describe your insurance coverage including professional liability, comprehensive liability, workers compensation, and others as appropriate. Please provide relevant certification of insurance.

3 Please list EI Services you are Certified/Licensed to provide: (SLP, OT, PT, ECSE, Social- Emotional, Nutrition, etc. Please circle School Districts you are willing to serve: ARAPAHOE COUNTY: Cherry Creek, Aurora Public, Littleton, Englewood, Sheridan, City of Aurora-in Adams County DOUGLAS COUNTY: (This is 1 school district with various locations) Highlands Ranch, Roxborough, Parker, Castle Rock, Sedalia, Franktown, Larkspur Are you interested in being a member of a Transdisicplinary Team? YES NO Please list insurances you can bill including Medicaid: (Please note your willing ness to bill insurance or Medicaid if you do not already do so.) CERTIFICATION AND RELEASE I certify that I have read and understand the entire Pre-Qualification of Vendors application and that the answers given by me to the foregoing questions and the statements made by me are complete and true to the best of my knowledge and belief. I understand that any false information, misrepresentation of facts, or omission called for in this application may result in rejection of my application or termination of any contract that may be in effect. I authorize the company and/or its agents to verify any of the information contained within this application. Signature: Date: MINIMUM PROTECTIONS Due to Federal Funding we are required certain minimum protections which are established by the granting agency. The protections include the following: 1. I will not engage in abuse, neglect or financial exploitation. 2. I do not have a history of convictions of abuse, neglect, mistreatment or physical harm to others 3. I will not be unjustly enriched by abusive financial arrangements with the individuals with whom I am working. 4. I am not and will not be the beneficiary of life insurance policies on those individuals receiving services (or their families). Please sign below to indicate your company s (or you as an individual s) written assurance of compliance with the above policies. Signature: Date:

4 Independent Contractor Status Service Provider certifies that it is engaged in an independent business and will perform its obligations pursuant to this Agreement as an Independent Contractor and not as the agent or employee of Developmental Pathways, Inc. As an Independent Contractor, Service Provider is not eligible for any benefits that normally accrue to an employee of Developmental Pathways, including, but not limited to, unemployment insurance, workers compensation, taxes, or benefits of any kind. This Agreement does not create a partnership, joint venture or similar relationship between the parties and neither party will have the power to obligate the other in any manner whatsoever. Service Provider declares that it has complied with all federal, state and local laws and regulations regarding business permits and licenses of any kind that may be required to carry out the said business and tasks to be performed under this Agreement. Indemnification. The Service Provider shall indemnify and hold harmless Developmental Pathways and its officers, employees and agents from and against any and all losses, damages, liabilities, claims, suits, or actions made or asserted for any damage to person or property occasioned by the acts or omissions of the Service Provider arising out of or in any way connected with the performance of services under this Agreement. The Service Provider s obligation to indemnify pursuant to this paragraph, and to provide any extended insurance coverage where applicable, shall survive the completion of the scope of services, and shall survive the termination of this Agreement. Signature: Date:

5 Experience and Other Information Related to Early Intervention Services and Supports Please outline, in detail, your experience with children 0-3. What type of work environment are you familiar with (your therapeutic input takes place at school, families home, office, etc.)? Describe your involvement with teaming with other professionals. With what age groups do you have experience providing services? What is your experience with Parent Education? What certification or special areas of focus/expertise do you have? How comfortable are you with providing services in environments that are part of the family s everyday routines, e.g. at home, in childcare settings, and other places in the community?