Agency Name *

Address 1 *

Address 2

City *

State *

Zip *

Phone *

Contact Person *

Contact Email

Agency Fax

Medicare Submission ID *

CMS Certification Number

Medicaid ID

State Code

Branch State

Branch ID

Federal Tax ID (FEIN) *

NPI *

Wage Index

Eligibility Verification?

checked value="1"/> Yes checked Value="0"/> No

Authorizations?

checked value="1"/> Yes checked Value="0"/> No

Intake data entry?

checked value="1"/> Yes checked Value="0"/> No

Admission QA?

checked value="1"/> Yes checked Value="0"/> No

Are you participating in the Review Choice Demonstration?

checked value="1"/> Yes checked Value="0"/> No

class="form-group hide"class="form-group" id="divclaim_review">

you need to answer the following:?

checked value="Pre_claim_review"/> Pre-claim review checked Value="Post_claim_review"/> Post-payment review

Hospice Medicare Provider Number

Hospice Medicare NPI Number

Hospice Medicaid Provider Number

Hospice Medicaid NPI

Mileage Rate *

Example: for $0.50 /mile, enter 0.50

Time Zone *

Rural add-on?

checked value="1"/> Yes checked Value="0"/> No

CAHPS Provider

SN Cost per visit

Therapy Cost per visit

Aide Cost per visit

Electronic Admission Forms?

checked value="1"/> Yes checked Value="0"/> No

Coding?

checked value="1"/> Yes checked Value="0"/> No

Number of SN visits without new orders - VBP

Visit Lock

checked value="1"/> Yes checked Value="0"/> No

Number of Goals per Certification PER DISCIPLINE - Maintenance

Patient Signature ends visit?

checked value="1"/> Yes checked value="0"/> No

EVV Transmission

checked /> Auto-send checked /> Review first

Auto-send transmits completed visits to EVV automatically. Review first requires manual transmission from the EVV Manual Transmission dashboard report.

PEGGii Patient Engagement

checked /> Yes checked /> No

Supervision Question 1

Supervision Question 2

Supervision Question 3

Supervision Question 4

Supervision Question 5

OASIS QA?

checked value="1"/> Yes checked Value="0"/> No

Faxing?

checked value="1"/> Yes checked Value="0"/> No

Billing Services?

checked value="1"/> Yes checked Value="0"/> No

H&P Review?

checked value="1"/> Yes checked Value="0"/> No

Dataset transmission?

checked value="1"/> Yes checked Value="0"/> No

CAHPS submission?

checked value="1"/> Yes checked Value="0"/> No

Logo to Upload

Note:

Logo Height must be less than 150 px and Width must be less than 350 px.

src="../../datafiles/Agency_Logos/#session.AgencyID#.png" style="max-height: 140px;"/>