Home Health Care Supplemental Application

The following information is required to submit a Home Health Care Supplemental Application. All information must be completed. Should you require assistance to complete this form, please contact your service representative.

Applicant Information



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    $
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  3. Types of Services Provided:

    Service Service Service
    Above must total 100%. Current Total: 0%
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  4. Employees / Independent Contractors – Annual Staffing:
      Employees Independent Contractors Annual Payroll
      Full Time Part Time Full Time Part Time Employees Independent Contractors
    Total: 0 0 0 0 $0 $0
    Acupuncturist
    Certified Nurse Anesthetist
    Clergy / Chaplain
    Clerical
    Dietitian
    Nurses (RN)
    Homemaker / Home Health Aid
    LPN / LVN
    Medical Director
    Nurse Practitioner
    Occupational Therapist
    Pharmacist
    Physical Therapist
    Physician
    Physician Assistant
    Psychiatrist
    Psychologist
    Respiratory Therapist
    Volunteers


Submission
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  • You may also print and fax this form for processing to: (718) 389-4300