Fillable HomeMakerCompany - Provider Profiles_1

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HomeMakerCompany - Provider Profiles_1

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PROVIDER TYPE PROFILE
PROVIDER
TYPE
37 HOMEMAKER
REIMBURSE-
MENT TYPE
02 FEE FOR SERVICE
EFFECTIVE 10-01-88
CATEGORIES OF SERVICE LICENSE/CERTIFICATION
MANDATORY 23 HOMEMAKER
MANDATORY
MANDATORY
OPTIONAL 26 RESPITE CARE
OPTIONAL 27 IHS OUTPATIENT SERVICE
OPTIONAL 28 ATTENDANT CARE
OPTIONAL 39 PERSONAL CARE SERVICE
OPTIONAL 46 ENVIRONMENTAL SERVICES MUST BE PROVIDED BY A
LICENSED CONTRACTOR OR AGENCY
OPTIONAL 47 MENTAL HEALTH SERVICES (EFFECTIVE 04/01/2008)
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
OPTIONAL
SPECIAL INSTRUCTIONS: MUST BE CERTIFIED IN CPR AND FIRST AID AND PROVIDE THREE
LETTERS OF REFERENCE FROM NON-FAMILY PERSONS. FOR COMPANIES THE
OWNER/PROVIDER IS RESPONSIBLE FOR MAINTAINING AND PROVIDING UPON REQUEST CPR
CARDS, FIRST AID CERTIFICATES AND LETTERS OF REFERENCE FOR EACH EMPLOYEE. BY
SIGNING BELOW YOU ARE INDICTING THAT THIS INFORMATION WILL BE KEPT ON FILE AND
MADE AVAILABLE UPON REQUEST.
COMPANY NAME ID NUMBER
SIGNATURE DATE
REVISED 05/08/2015
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Completed 20 November 2019

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