Direct Service Purchase Provider Inquiry Form

Direct Service Purchase Provider Inquiry Form

Agency Name*

Address*

Phone Number*

Phone

Today's Date

Contact Name*

Agency Website Address*

Email Address*

Services Provided*

In-Home Care

Nursing

DME (Medical Supplies)

Transportation

Chore - Lawn/Snow

Home Delivered Meals

Personal Emergency Response (PERS)

Out-of-home Respite

Residential (AFC/HFA)

Adult Day Health Facility

Home Modifications

Community Health Worker (CHW)

Service Area*

Macomb

Oakland

Monroe

St. Clair

Livingston

Washtenaw

Insurance Coverage*

Do you have ALL of the following required insurance coverages?

Unemployment
Worker’s Compensation
General Liability- $1,000,000 limit each occurrence
Employee Dishonesty $50,000 Limit to cover both First Party and Third Party (theft of client’s property) crime
Automobile Liability- $1,000,000 limit (covering owned, hired, non-owned)
Professional Liability- Required for Nursing/Licensed Services

Select

Additional Affiliations*

Are you currently working with another MI Choice waiver agency?

For example, Detroit Area Agency on Aging, MORC, Senior Alliance, Region 2 AAA, Valley Area Agency on Aging, Tri County Office on Aging, A & D Home Health Care, Region 7 Area Agency on Aging.

Select

Length of Operation*

Has the agency been in business for greater than 1 year?

Select

Home Care Agencies Only

Number of employees

How many caregivers does the agency currently employ?

Languages

Please select any language services, other than English, that your agency provides

Select or enter value

Capacity

How many hours of direct care is your Agency able to staff?

Supervisory Requirements

Do you employ a MDHHS Licensed Nurse (RN) who can perform supervisory visits for CLS workers at least twice per year?

Select

Licensed and Unlicensed Residential Facilities ONLY

License Number

Facility (Home) Name

Facility (Home) Address

Bed Count

Additional Facilities (Homes)

Additional Information

Please enter any additional information that you would like to share about your agency or the services you provide.

Acknowledgement*

I understand that this inquiry is not a complete application. Completion of this inquiry is only the initial step in the process and does not automatically qualify my agency as an Ageways DSP network provider.

Send me a copy of my responses

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