Okaloosa County BOCC — January 19, 2016 — Access 2 Care Vendor Application

AccessZCare Non-Emergency Transportation Vendor Application PLEASE CHECK THE FOLLOWING TO MAKE SURE YOU'VE SUBMITTED A COMPLETE APPLICATION: 1. Have you completed all provider information? 2. Have you attached a copy of your insurance coverage? 3. Have you attached a copy of your business license? 4. Did you sign the application? Company Information Legal Name of Service: DBA: Okaloosa County Board of county Commissioners Emerald Coast Rider Corporate Street Address: City: 101 E. James Lee Blvd #104 Crestview County: State: Zip Code: Phone: Okaloosa FL 32536 850-651-7200 Fax: E-mail: Federal Tax ID Number (or SS# if sole proprietor) 850-689-4272 59-6000765 Mailving Address: (ifdifferent) €00 Transit Way City: State: Zip Code: Fort Walton Beach FL 32547 If multiple locations, please attach a separate list of all applicable service locations, addresses and contact information 1. Names of contacts for your business: Name Title Phone Email Janet Willis Transit Coordinator 850-609-7003 jwillis@co.okaloosa.fl.us Marcella Eubanks Contracts & Grants Manager 850-651-8000 meubanks@okaloosaclerk.com 2. Please identify the types of service you provide AND the number of vehicles you use in regular service X Ambulatory (9) X Wheelchair (45) Stretchers Other: _Service -2 Ambulances 3. Will your drivers assist ambulatory members if necessary (i.e., frail and/or elderly patient)? Yes X No If yes, indicate specific assistance: (check all that apply) X To/From Front Door X Up/Down Steps _ x Inan Elevator _x To a Check-In Desk. Page I of 5 AccessZCare 4. Will your drivers assist riders as they transfer from wheelchair to seat? Yes X No S. If you use sedans, will you transport a person who is in a wheelchair, but who is capable of “scooting” from the chair to the vehicle and have the wheelchair folded up and placed in the trunk? Yes X No (Note: This is not appropriate for van use because the stowed wheelchair can become a flying/harmful object within the vehicle in the event of a crash if it is not properly secured) 6. Can you provide attendants to stay with the rider during entire medical appointment, if necessary? Yes No_ X Do you contract with an organization that provides attendants? Yes No__ X 7. Do you provide child restraint seats? Yes X No If no, would you consider purchasing car seats as needed? Yes No (Note: If you do not have child restraint seats, you may not accept any trips that ask for a child seat to be provided by the transportation provider) 8. What is your present service area in which you would like to receive trips for pickup? Please list them by county. If you do not service the entire county, please specify the zip codes you service. Include a separate sheet if needed. County Zip County Zip County Zip Okaloosa Co. **Do not travel out-of-state 9. Are you will to accept van or paralift trips outside of your local area if needs arise? Yes X No 10. Are you able and willing to accept same day requests? Yes_ x* No *Dependent on available resources Page 2 of 5 AccessZCare 11. What are your regular business hours (when your office is open)? Monday - Saturday__7:30 - 430pm M-F Sundays/Holidays_No Sundays™- select holidays 12, What are your days and hours of regular transportation service? (our system will not schedule a trip within one hour of start/stop time) Monday - Saturday 6:00a —= 11:00 p Sundays/Holidays_7a - 7p (limited resources) 13. What is the maximum number of daily round trips you are willing to accept within your service area? Ambulatory Wheelchair Other Resources & destination depender 14. Will you agree to place a phone call to each rider informing them of pickup time, and confirm pickup arrangements? Yes No_x 15. What is your primary communication system with vehicles/Drivers? Please check all that apply: 2-Way Radio Cell Phone_ X Other 16. Does your business qualify for your State’s “Minority-Owned Business Enterprise” (MBE)? NA Yes No (Note: MBE usually means U.S. citi