AgencyTrust Information Form Save my progress and resume later | Resume a previously saved form Resume Later In order to be able to resume this form later, please enter your email and choose a password. Your Email: A Password: Confirm Password: Agency Name Agency or Corporation Name Agency D/B/A (or Assumed Name if applicable) Registered "Doing Business As" or 'Assumed" Name for your corporation Agency Phone Number: Agency E-mail Agency Website Agency TypePlease select... Non Med Home Care / Personal Assistance Services State Licensed Home Health Medicare Certified Home Health Office Hours Example - Mon to Friday 8.00 am to 5.00 pm Agency Address Street Address Address continued City StatePlease select... Please select Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Puerto Rico Virgin Island Northern Mariana Islands Guam American Samoa Palau Zip Agency Managerial Roles & Owner Details Administrator or Manager Name Director Of Nurses Name or Supervisor Name Owner Name: (add at least one verifiable owner) Upload Owner ID: (driving license or any state/federal issued Upload Your Agency Privacy Policy Upload Your Agency Background Checks Policy Upload Additional Policies That Cover Privacy (optional if needed). Upload Additional Policies That Cover Privacy or Background Checks - Such as Aide Registry checks or Abuse Registry checks etc. Anything applicable to your state law. (optional if needed). Agency License Number (state issued if applicable) Upload Your Agency License Provided By Your State *If the agency in Non Medical & your state does not require licensing then ignore this section and *LOOK BELOW *Non Med Agencies where the state does not license Home Care (only) *Non Med Agencies where the state does not license Home Care (only) - Please Upload any Policies that show compliance with any state law that is required to operate a home care agency in the non licensed state - ignore if already uploaded above background check policy and that is all the state requires. Additional Policy upload if needed Policies Required Additional Information (optional) If you have any further information that you would like to send us (Place your text here) Order# (this was emailed to you) reCAPTCHA helps prevent automated form spam. The submit button will be disabled until you complete the CAPTCHA. Save my progress and resume later | Resume a previously saved form Contact Information
