Home Health Agency Application

Name of Facility/Agency
Facility License Number
Administrator
Preferred Contact (for H2H Opportunities)
Phone
Email
Facility Address
City
State
Zip Code
Phone
Fax
Mailing Address (if Different than Facility Address)
City
State
Zip Code
Phone
Fax
Geographic Area Served by Facility/Agency (List County or Counties within North and South Carolina)
Check Type of Services Provided
  • Skilled Nursing
  • Physical Therapy
  • Occupational Therapy
  • Speech Therapy
  • Medical Social Services
  • Home Health Aid Services
  • Medical Supplies and Appliances
  • Homemaker Services
  • Other (please specify below)
Check Type of Legal Entity
Select One
For Profit Non-Profit
Is This Agency Medicare Certified?
Yes No
If Yes, Provide Medicare Provider Number
Is This Agency Medicaid Certified?
Yes No
If Yes, Provide Medicaid Provider Number
Is Your Facility/Agency Accredited by?
Yes No
If Yes, Name the Accrediting Organization
Expiration Date
Is the Facility Chain Affiliated?
Yes No
If Yes, List Parent Company Address
City
State
Zip Code
Phone
I attest that the information above is true and accurate. Please keep me informed of Health2Home preferred participation opportunities. I understand this application does not commit our organization in any way; however, it does allow us to receive information from Health2Home about new opportunities which we may consider. I understand there is no fee to join the Health2Home Network and that my participation can be terminated at any time.