| Company Name: | |||||||||
| Company EIN#: | |||||||||
| Consultant Name: | SSN: | ||||||||
| Consultant Address: | |||||||||
| Consultant Phone/Fax/Email: | |||||||||
| The following items are Required: | |||||||||
| ¨ Resume | ¨ Orientation Check List | ||||||||
| ¨ Three Letters of Reference | ¨ LEL Policies | ||||||||
| ¨ W-9 | ¨ HIPPA Agreement | ||||||||
| ¨ Valid Driver’s License (current) expiration: | ¨ Conflict of Interest | ||||||||
| ¨ Social Security Card | ¨ Consultant Agreement | ||||||||
| ¨ Vehicle Insurance Card (current) expiration: | ¨ Receipt of LEL CD form | ||||||||
| ¨ Negative TB test (within past 3 months) expiration: | ¨ LEL-BQIS Checklist | ||||||||
| ¨ CPR expiration: | ¨ Role Description | ||||||||
| ¨ First Aid Card expiration: | ¨ Letterhead (consultant) | ||||||||
| ¨ Copy of Diploma | ¨ Business Card (consultant) | ||||||||
| ¨ State FULL Criminal History Check ($10 check with fingerprints) expiration: | |||||||||
| ¨ A&D/TBI/All Medical Model Waivers Federal Criminal History Check ($39 with fingerprints) expiration: | |||||||||
| ¨ County FULL Criminal History Report expiration: | |||||||||
| ¨ Acknowledgement of Waiver | |||||||||
| ¨ Waiver of Claims | |||||||||
| ¨ Receipt of LEL Blue Book form | |||||||||
| ¨ Memo of Understanding & Agreement | |||||||||
| ¨ Required 12 hours training (due within the year of beginning services & every year after) | |||||||||
| ¨ Individual Rights, Medication Administration and BDDS Incident Reporting Standards | |||||||||
| are required within first 12 months (free training is available through Kirkland & Assoc.,LLC) | |||||||||
| Additional requirements for LLC’s (completed by business entity): | |||||||||
| ¨ EIN/TIN # IRS Notice | |||||||||
| ¨ W-9 for LLC | |||||||||
| ¨ Certificate of Organization | |||||||||
| ¨ Voided Business Account Check | |||||||||
| ¨ Letterhead/Business Card | |||||||||
| ¨ Certificate of Insurance | expiration: | ||||||||
| ¨ Memo of Understanding | |||||||||
| ¨ Conflict of Interest | |||||||||
| ¨ Acknowledgement of Waiver | |||||||||
| ¨ Waiver of Claims | |||||||||
| ¨ HIPPA Business Associate Agreement | |||||||||
| ¨ LEL Policies | |||||||||
| ¨ Role Description | |||||||||
| ¨ Proof of Orientation | |||||||||
| ¨ Proof of 2 years tax responsibility | |||||||||
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