Wisconsin In-Network Transportation Provider Checklist

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LOGISTICARE INSURANCE CREDENTIALINGCHECKLISTProvider_____________________________________________Insurance Certificate on file?Yes □ No □A current copy of your Insurance Certificate needs to be submittedalong with the information below.CREDENTIALINGTYPEGeneral Liabilityw/ ”Broad Form”coverage($500,000)EXPIRATIONDATEAMOUNTVERIFIEDBYCOMMENTSAdditionalCoverage forSexual Abuse &Molestation (SAM)WorkersCompensationVehicle Insurance($500,000)Any Auto must beselected as part ofcoverage.LogistiCareAdditionalInsuredLogistiCareCertificate HolderAdditional Comments________________________________________________________________________________________________________________________________________________________________________________________________________________________Page 48
Transportation Network Development503 Oak Place, Suite 500Atlanta, GA 30349Phone (800) 486- 7642, Fax (877) 352-5641LOGISTICARE PROVIDER NETWORK QUESTIONNAIREPlease provide all the requested information to the best of your ability via fax AND mail the original.If you need more space, please write on the back or attach a separate sheet. Thank you.COMPANY CONTACT INFORMATIONCOMPANY NAME:STREET ADDRESS:MAILING ADDRESS:CITY: STATE: ZIP CODE:PHONE:FAX:EMAIL: WEB SITE :Which of the following best describes your company? Private____ Not for Profit_____ Taxi _____ Transit Agency______Human Services Agency_____ Agency on Aging _____ Faith Based Organization______NAME OF PERSON AUTHORIZED TO ENTER COMPANY INTO CONTRACTUAL OBLIGATIONS:NAME:TITLE:PHONE #: FAX: EMAIL:BASIC OPERATIONS INFORMATIONIn what State do you operate? ____________________________________________________________________________How many total vehicles do you operate in the state? __________________________________________________________How many vehicles do you operate per county by type (Total must equal number above)? Please fill below:CountySedan– NonTaxi TaxiMiniVanFullSizeVanADAWheelchairVanNon-emergencyStretcher/GurneyBLSAmbulanceALSAmbulancePlease complete with number of vehicles by type in each countyOther(pleasespecify)How many drivers do you employ? ______ How many office personnel? ______ How many other? ______Page 49
Page 1 and 2: Please return all documents to:1275
Page 3 and 4: TRANSPORTATION AGREEMENT(the “Agr
Page 5 and 6: Provider may be withdrawn by LGTC,
Page 7 and 8: ii)iii)iv)scheduled B-Leg pick up t
Page 9 and 10: utilized by Provider.ii) The number
Page 11 and 12: • ADA regulations;• Client Cont
Page 13 and 14: vi)type of vehicle in which it is i
Page 15 and 16: and satisfactorily cleared a nation
Page 17 and 18: ix)a Participant, or in the presenc
Page 19 and 20: iv)Provider warrants that it has no
Page 21 and 22: a) name, date of birth and social s
Page 23 and 24: from establishing or maintaining se
Page 25 and 26: the dispute shall be referred for b
Page 27 and 28: EXHIBIT ALIQUIDATED DAMAGESThe Part
Page 29 and 30: Requirement:Provider must perform t
Page 32 and 33: To determine the payment amount LGT
Page 34 and 35: Exhibit B - Execution PageLOGISTICA
Page 36 and 37: scope of the employment or other pr
Page 38 and 39: or created or received by BUSINESS
Page 40 and 41: presenting a preponderance of the e
Page 42 and 43: EXHIBIT EMedicare Advantage Program
Page 44 and 45: information and data necessary for:
Page 46 and 47: e reviewed and approved by Health P
Page 48 and 49: Non-Emergency Medical Transportatio
Page 52 and 53: Please describe your hours of opera
Page 54 and 55: Network Development503 Oak Place, S
Page 56 and 57: AFTER HOURS CONTACTINFORMATION SHEE
Page 58 and 59: Form W-9 (Rev. 1-2003) Page 2Exampl
Page 60 and 61: Form W-9 (Rev. 1-2003) Page 4Part I
Page 62 and 63: Dear LogistiCare Transportation Pro
Page 64 and 65: Electronic Data Interchange (EDI) A
Page 66 and 67: Date: __________________________Log
Page 68 and 69: Software User AgreementWHEREAS, Log
Page 70 and 71: III.OWNERSHIPThe Software is protec
Page 72 and 73: X. THIRD PARTY WEBSITESThe Software
Page 74 and 75: (B) The Content may not be copied,
Page 76 and 77: this Agreement, or the infringement
Page 78 and 79: LogistiCare Driver ListLegal name D

Wisconsin In-Network Transportation Provider Checklist

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