HHES Intake Form
Please provide all required details to tell us about your Agency
Legal Agency Name
*
Other Name(if applicable)
Type of Agency
*
Please Select
Homecare Agency- Non Skilled
Private Duty Agency
Skilled Home Health- Seeking Accreditation
Skilled Home Health - Accredited
Others, please specify below:
Tax Identification Number (TIN)
National Provider Identifier (NPI)
IRS Designation
Please Select
Proprietary
Non-Profit (requires IRS Form 501(c)(3)
Disregarded Entity (Requires Form 8832)
Business Structure
Please Select
Corporation
Limited Liability Company
Partnership
Sole Proprietor
Notify us if this is a Federal and/or State Government entity with the following affiliations: Federal, State, City, County, City-County, Hospital District
Agency Contact
*
First Name
Last Name
Contact Number
*
Work E-mail
*
example@example.com
Business Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Other
*
Any additional information:
Ready to Start Application Process:
Submit
Should be Empty: