*Required fields

1. Practice information

Practice name
Practice type
Home care agencyCare management companyOther practice type
Street address
Street address line 2
City
State
ZIP code
Business phone
Business fax

2. Primary contact

First name
Middle initial
Last name
Title
Phone number
Email
Email for invoice notification
Legal status
Sole proprietorshipGroup practiceLLCCorporationPartnershipOther legal status

3. Geographical areas served

State served
County or counties served
Distance willing to travel

Note: Care managers are expected to travel at least 25 miles to see a member. 

Services provided (separated by commas if multiple)
Comments
Would you like to add another state?
NoYes

4. Practice license(s)

License number
License type
State
Expiration date
Would you like to add another license?
NoYes

5. Attachments

Certificate of Insurance (General and Professional Liability and Worker's Compensation)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
W-9 FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Humana At Home Ownership DIsclosure FormAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Certificate of Good Standing from the Secretary of StateAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Letter of Agreement (submit all pages)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Health Insurance Portability and Accountability Act (HIPPA) Business Associate Agreement (submit all pages)Accepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
IT Security AgreementAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Business or Occupational LicenseAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.
Humana At Home Onboarding ChecklistAccepted file types include .doc, .docx and .pdf with a maximum size of 5 MB.

6. Submittal

Submit my form to

I certify that all of the representations made above are accurate and truthful. I represent that in working with Humana At Home℠ Care Management Network, my company, employees, subcontractors and I agree to abide by the Code of Ethics of our parent profession(s).