 |
Executed contract |
|
Completed CareGuide Application with signed
and dated Attestation listing each location |
|
Copy of W-9 and Certification form |
|
Copy of facility state license |
|
Copy of Facility DEA certificate |
|
Copy of current liability and Professional
insurance certificate ($1 million per incident, $3 million in
aggregate) or state requirements |
|
Any adverse actions within the last five
years |
|
Copy of most current state survey (correction
plans, and letter from the state accepting said plan, if applicable) |
|
Proof of Medicare and/or Medicaid certification |
|
JCAHO, CARF, AAAHC or CHAP certificate
(if applicable) |
|
Copy of Medical Director's current, valid
state medical license, DEA certificate, malpractice insurance
certificate |
| |
|
