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.

Click the Browse Buttons to upload corresponding files(2MB Max). If you can't see the Button, please install Adobe flash HERE

3. Fill out form completely.

* (required)

Service Type:
Agency/Organization Name *
Agency/Organization DBA Name *
Tax ID#(TIN) * Are multiple TINs used
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 LPN Visit
Home Health Aide (HHA) Skilled Nursing Evaluation
Home Health Aide (HHA) Hourly Skilled Nursing-RN Visit
High Tech RN Visit Skilled Nursing-LPN Visit
High Tech RN Visit Hourly Skilled Nursing-RN Hourly
High Tech LPN Visit Skilled Nursing-LPN Hourly
High Tech LPN Visit Hourly (MSW) Master Social Worker
LPN Hourly Therapy Visit (PT/OT/ST)
Therapy Evaluation (PT/OT/ST)    
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
All 'E' Codes
All 'K' Codes
All 'L' Codes
All 'Q' Codes
All 'V' Codes
Infusion Therapy Include Drug/Therapy Exceptions
Anti-Infective Therapies
Specialty Injectibles
Parenteral Nutrition (TPN)
Pain & Palliative Care
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)
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.
 
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