Partner with Us Partner With Us Partner with Us (Become a VetAssist Provider)First Name(Required)Last Name(Required)Title(Required) Partner with Us (Become a VetAssist Provider)Your DBA Company Trade NameYour Company Legal Business Name(Required)Company Info(Required) Company Street Address 1 Company Street Address 2 Company City Company Zip Code Company State(Required)- Select State -ALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWYAAAEAPOffice Phone Number(Required)Cell Phone Number(Required)Fax NumberEmail Address(Required) Month & Year Business Started(Required) Partner with Us (Become a VetAssist Provider)How many total active clients do you currently have in your agency census?(Required)Do you have a client to refer to the VetAssist Program today?(Required) Yes No Is Your Business Licensed?(Required) Yes No What Types of Insurance Does Your Business Carry?(Required) Workers Compensation Insurance Professional Liability Insurance General Liability Insurance None Partner with Us (Become a VetAssist Provider)Does your agency have multiple locations?(Required) Yes No Current Home/Day Care Private-Pay Rate(Required)Does Your Agency Accept Medicaid?(Required) Yes No What is The Medical Rate for Home Care or Daycare in Your Area?Are you currently contracted with the Veterans Administration Community Care Program?(Required) Yes No Partner with Us (Become a VetAssist Provider)Does your agency provide transportation services?(Required) Yes No Have you attended our Intro to the VetAssist Program webinar?(Required) Yes No How Did You Hear About Us?(Required)Comments
