World Services Network

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Tel: (800)493-4839
Fax: (404) 596-8095

Home
Our Services
Providers
- Home Health / DME
Careers
- Languages Services Application
About US
- Contact Us
- Privacy Policy
Referrals
Tel: (800)493-4839
Fax: (404) 596-8095

Apply HH DME: World Services Network

Home Health · DME · Infusion Therapy Provider Application

1. Consent for Release of Information and Release of Liability forms

Please Download, Sign, and Email us: info@worldservicesusa.com

2. To better serve you, please do not forget to submit required documents. Only pdf, docx or doc file, 2MB Max.

Click to upload W9.

Start Date:

Expiration Date:

Click to upload Business License.

Start Date:

Expiration Date:

Click to upload HH License.

Start Date:

Expiration Date:

Click to upload Insurance.

Start Date:

Expiration Date:

Click to upload Service Rate.

Click to upload Other Documents.

Accreditations

Type:		Click to upload Accreditations.
Approval Date:		Expiration Date:

3. Fill out form completely.

* (required)

Service Type:

Agency/Organization Name *

Agency/Organization DBA Name *

Tax ID#(TIN) *

Are multiple TINs used

Yes No

NPI#

State License# *

Physical Address:

Address *
City *	State *	Zip *
Phone *	2nd Phone *	Fax *

Billing Address:

Same as Physical Address
Address *
City *	State *	Zip *
Phone *	2nd Phone *	Fax *

Hours of Operation:

Day	From	To	Day	From	To
Monday			Tuesday
Wednesday			Thursday
Friday			Saturday
Sunday

Credentialing Contact Information:

Name *	(Name of Provider or Representative for credentialing prupose)
Phone *		Extension	Fax
Email *
Name/TIN of Parent Organization(if applicable)			TIN

Covered Services: (Please check all appropriate services provided below:)

Discipline/Services	Include	Discipline/Services	Include
Companion/Hourly	Yes No	LPN Visit	Yes No
Home Health Aide (HHA)	Yes No	Skilled Nursing Evaluation	Yes No
Home Health Aide (HHA) Hourly	Yes No	Skilled Nursing-RN Visit	Yes No
High Tech RN Visit	Yes No	Skilled Nursing-LPN Visit	Yes No
High Tech RN Visit Hourly	Yes No	Skilled Nursing-RN Hourly	Yes No
High Tech LPN Visit	Yes No	Skilled Nursing-LPN Hourly	Yes No
High Tech LPN Visit Hourly	Yes No	(MSW) Master Social Worker	Yes No
LPN Hourly	Yes No	Therapy Visit (PT/OT/ST)	Yes No
Therapy Evaluation (PT/OT/ST)	Yes No

Covered Services: (Please check all appropriate categories of services provided to include a list of DME HCPCS and/or Products below:)

Durable Medical Equipment	Include	Code Exceptions
All 'A' Codes	Yes No
All 'E' Codes	Yes No
All 'K' Codes	Yes No
All 'L' Codes	Yes No
All 'Q' Codes	Yes No
All 'V' Codes	Yes No
Infusion Therapy	Include	Drug/Therapy Exceptions
Anti-Infective Therapies	Yes No
Specialty Injectibles	Yes No
Parenteral Nutrition (TPN)	Yes No
Pain & Palliative Care	Yes No

Add Languages Provided:

Add the languages provided (Important).

(Chose a language and click button for each language to add.)

Add zip code of Services Areas:

Add the zip codes of ALL the areas in which you provide transportation services (Important).

(Input and click button for each 5-digital zip code to add，zip code only)

Yes No

<- The information provided on this application applies to all additional locations?

If yes, please attach a list of additional locations, providing location name, address, phone, fax, NPI#, TIN# and a credentialing contact.
If no, please complete this application for each location with varying information.

Note: Please be advised, the next phase of the World Services LLC Services enrollment process is a successful completions of World Services LLC's credential verification program.
A team member will contact you directly gathering and verifying information required for credentialing.