Dina Provider Credentialing

Dina Provider Credentialing
Contact Information
Name*

First NameLast Name
Job Title
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Organization Information
Legal Name of Company/Organization*
DBA (if applicable)
Type of Entity*
Federal Tax ID (EIN)*
NPI (Type 2)
Medi-Cal Provider ID
HCO License #
Business Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address (if different than above)

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email*
example@example.com
Web Site

Primary Contacts

[Section 2 of 9]
Please provide contact information for the following roles:
Executive Director
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
Credentialing Contact
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.
RN / Clinical Oversight
Name

First NameLast Name
Email
example@example.com
Phone Number
Please enter a valid phone number.

Organization Details

[Section 3 of 9]
Service Area Zip Codes or Counties
Service Area Notes (Optional)
Languages Spoken

EnglishSpanishGermanDutchChineseVietnameseKoreanOther
Number of Employed Caregivers
Other Services Offered
Average Tenure of Caregivers
In Years
Hours of Operation
Does your agency have a minimum number of hours required per visit? If so, what is the minimum duration?
Does your agency accept housekeeping only referrals?

Staff & Caregiver Credentialing

[Section 4 of 9]
Attach your Policies & Procedures that demonstrate the organization collects and maintains the following for all caregivers.

NOTE: Provider must be able to furnish these documents for any caregiver upon request.
Background Check

(within 6 months)
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
OIG / LEIE Exclusion Screening

(within 3 months)
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Licensure / Certification

if applicable
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
HCA Registry Verification
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.

Health & Safety Documentation

[Section 5 of 9]
Attach your Policies & Procedures that demonstrate the organization collects and maintains the following for all caregivers:
RN Risk Assessment or Pre-Employment Physical
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
TB Test

(within 3 months)
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Pre-Employment Drug Screening
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Annual TB Questionnaire
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Annual Flu Vaccine or Declination
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
NOTE: Provider must be able to furnish these documents for any caregiver upon request.

Required Training & Orientation

[Section 6 of 9]
Attach Policies & Procedures, and Training Materials used, documenting required training and orientation protocols:
Initial Competency Assessment
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Annual Competency Assessment
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Bloodborne Pathogens Training
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Emergency Preparedness Training
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
OSHA / Workplace Hazards Training
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
HIPAA Training
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
CPR / First Aid Certification
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Gender-Affirming Care Training

(California SB 923)
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Job-Specific Training
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
PACE Mission Orientation
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
NOTE: Provider must be able to furnish these documents for any caregiver upon request.

Organizational Policies

[Section 7 of 9]
Attach copies of:
Incident Reporting Policy
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Client Rights & Responsibilities
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Quality Assurance Plan
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
HIPAA Compliance Program
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
EVV Policy

(if used)
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Infection Control Protocols
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Example Visit Note Documentation

Visit notes must include Participant name, Shift date including clock-in and clock-out times, Tasks/ADLs performed, Comments for tasks NOT performed (e.g., "ppt refused", "no dirty laundry at this time", etc.)
Visit Note Examples

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.

Insurance & Licensure

[Section 8 of 9]
Attach copies of:
Business License
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
HCO License
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
General & Professional Liability Insurance
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Workers' Compensation
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.
Auto Insurance

(if transportation is offered)
Policies & Procedures

Cancelof
Optional Notes
Applicable page numbers, descriptions, or comments.

Attestation

[Section 9 of 9]
Final Comments or Notes (Optional)
Can you sign this credentialing form?*
Signer's Name

First NameLast Name
Signer's Email
example@example.com
I attest that the information provided is accurate and complete.
Signature

Clear
Name

First NameLast Name
Title
Date

MonthDayYear
Date
Should be Empty:

Dina Provider Credentialing

Contact Information

Organization Information

Primary Contacts

Executive Director

Credentialing Contact

RN / Clinical Oversight

Organization Details

Staff & Caregiver Credentialing

Background Check

OIG / LEIE Exclusion Screening

Licensure / Certification

HCA Registry Verification

Health & Safety Documentation

RN Risk Assessment or Pre-Employment Physical

TB Test

Pre-Employment Drug Screening

Annual TB Questionnaire

Annual Flu Vaccine or Declination

Required Training & Orientation

Initial Competency Assessment

Annual Competency Assessment

Bloodborne Pathogens Training

Emergency Preparedness Training

OSHA / Workplace Hazards Training

HIPAA Training

CPR / First Aid Certification

Gender-Affirming Care Training

Job-Specific Training

PACE Mission Orientation

Organizational Policies

Incident Reporting Policy

Client Rights & Responsibilities

Quality Assurance Plan

HIPAA Compliance Program

EVV Policy

Infection Control Protocols

Example Visit Note Documentation

Insurance & Licensure

Business License

HCO License

General & Professional Liability Insurance

Workers' Compensation

Auto Insurance

Attestation