Trillium Valued Providers Seal Program

Providers may use and display these Valued Provider Seals only with the express written permission of, and in accordance with the rules and restrictions established by, Trillium Health Resources. Any unauthorized use, disclosure or distribution of these Trillium seals is prohibited by Trillium and may result in the imposition of sanctions related to such unauthorized use, disclosure or distribution, up to and including termination of the provider’s contract with Trillium.

Provider Name*

Provider Address*

Provider Contact Person*

Provider Contact Number*

Provider Email Address*

Seal of Interest*

Please select all that apply.

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How many window/door sticker decals are needed?*

You will receive the same number of stickers for each Seal type issued.

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Are you a credentialed provider in Trillium Network?*

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Are you accredited by an approved accrediting body?*

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Have you completed Cultural Competency training?*

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Share three ways/examples of how you are a culturally competent provider and attach/upload supporting documentation below to show that you have a cultural competent plan.*

Submit a paragraph telling us how your cultural competent plan has been implemented within your organization.*

Do you provide three or more services on the continuum of care?*

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Do you have an attributed population served of more than 150 members annually and/or provide services to Trillium members that reside within 10 different counties in North Carolina?*

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Do you provide at least two evidenced based treatment modalities?*

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Do you provide three or more services for the I/DD population?*

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Have you received any Type A deficiencies/violations within the last year?*

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Have you received any Type B deficiencies/violations within the last year?*

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Do you participate in a consumer satisfaction process involving residents, family members and guardians?*

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Do you participate in Trillium provider satisfaction surveys?*

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Do you have a stable workforce that includes back up staffing for members?*

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Do you provide targeted in-service training to meet training needs of your workforce? If yes, please attach/upload supporting documentation below. (Ex. sign-in sheets or a similar process)*

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File Upload

Please upload all supporting documentation here:

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