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RCOM Form
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22
Questions
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1
How did you hear about us?
*
This field is required.
Please Select
Referral
Facebook
Business Card
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Please Select
Referral
Facebook
Business Card
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2
If referred, by who?
If not referred, click 'next'.
Name of person who referred you.
Please enter a phone number
Please enter your email
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3
Is your business name registered with the KY Secretary of State?
YES
NO
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4
Name of company needing consulting services?
If it is NOT REGISTERED with KY SOS please type NR at the end of your business name.
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5
Address
Please enter the full address of new or established company.
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Please Select
Please Select
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
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6
Please enter the following information.
Type "NEED" if needed. Type "NA" if non-applicable.
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7
Please list the Name, Email, Address, and Phone Number of ALL Owners.
Owners that own more than 5% interest in the company.
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8
The following information is for KY Medicaid Provider Enrollment only.
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9
Full Name and Title of your Company Officers
(I.e. Executive Director, CEO, Operations Manager, CFO, COO, etc.) If position is not filled yet chosen, please enter Title and list as 'vacant'.
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10
Primary Company Contact Email
example@example.com
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11
Name of your preferred Registered Agent
*
This field is required.
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12
If Project was selected from the previous question, please check all that apply.
If not, click 'next'.
Training: Medication Administration
Independent Serious Incident Investigations
Policies and Procedures (KY Medicaid)
Policies and Procedures (Commercial Insurance)
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13
Type of KY Medicaid Program or Waiver
If certified, type certified. If needed, type need.
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14
Please list your business needs in order starting with your top priority.
Click the + to add more fields.
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15
Please list any other business needs or aspirations you have identified for your company or would like to achieve as a New or Veteran Entrepreneur.
Click the + to add more fields.
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16
I am interested receiving additional information on the following RCOM services:
Check all that apply.
Quarterly Minutes Template
Operating Agreement
Business Plan
6 Month Budget
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17
Please send me free information about the following services.
Check all that apply..
Law Services
Social Media/Email Marketing
Contracts for Services or Individuals
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18
Number of hours requested for Consulting Contract/Retainer:
Max 5 increments of 10 hours. Example: 1=10, 5=50
1
2
3
4
5
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19
Contract Type
Check all that apply.
General Business Consulting (Non-Medicaid)
KY Medicaid Waiver Specialized Business Consulting
Project(s) 1. Training: Medication Administration 2. Independent Serious Incident Investigations 3. Policies & Procedures (KY Medicaid) (Commercial Insurance) *Flat Fee
KY Medicaid related Expert Witness Services for Criminal, Civil, and Administrative Hearings
Purchasing/Acquiring/Selling a Business
Assisted Living
Personal Care Home
FCH (Family Care Homes)
Home Health
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20
RCOM Consulting's Premium Packages
Our Premium Consulting Packages give you priority status in consulting and other added perks/discounts.
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21
Package Selection
Please select one.
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Great Product Name
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ORDER SUMMARY
Total cost
USD
(A) Master Executive Package
$675 per hour
$
675.00
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100
100
100
Quantity
(B) Leadership Package
$650 per hour
$
650.00
+
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85
85
85
Quantity
(C) Platinum Package
$625 per hour
$
625.00
+
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70
70
70
Quantity
(D) Gold Package
$600 per hour
$
600.00
+
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55
55
55
Quantity
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22
Method of Payment
Please select your payment method below. We will email your an invoice to you. The 5% fee will be added to your invoice if the Credit Card method is chosen.
Credit Card (5% Fee)
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