Supporting Documents
Attach appropriate documents on each section for consultant to review
EIN/TAX ID NUMBER(TIN)
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NPI NUMBER
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BUSINESS TAX RECEIPT
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BUSINESS TAX RECEIPT
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LETTER FROM ZONING OFFICIALS-indicating business location is Zoned for Home Care Business
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COPY OF LEASE/RENTAL AGREEMENT
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PROFESSIONAL LIABILITY/MALPRACTICE INSURANCE
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CLIA CERTIFICATE (if applicable)
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MEDICAID LICENSE (if applicable)
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FINANCIAL STATEMENTS(sample Form 3100-0009 financial ability to operate)
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SIGNED BUSINESS PLAN( include plan for delivery of service, details on provider's methods to obtain patients and its plan to recruit/maintain staff)
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DOCUMENTATION OF CHANGE OF OWNERSHIP (if applicable- include effective date of change and execution by all parties)
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RESUMES FOR KEY PERSONNEL/STAFF (Administrator/DON/Clinical Manager if available)
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