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

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. citizen(s), a sole proprietorship, partnership, corporation or joint venture, owned, operated and controlled by a minority group member or members who have at least 51 percent ownership. The minority group member(s) must have day-to-day operational and managerial control, and an interest in capital and earnings commensurate with his/her/their ownership. Minority is generally defined as belonging to one of the following racial minority groups: African Americans, Native Americans, and Hispanic Americans, Asian Americans or other similar racial groups.) If yes, is your company a Certified MBE? Yes No If so please provide us with a copy of your certificate. If not, are you interested in becoming certified? Yes No 17. Does your business qualify for your state’s “Women-Owned Business Enterprise? (WBE)? NA Yes No (designation not available in all states; description is above, replace “woman” for “minority™.) If yes, is your company a Certified WBE? Yes__ No___ If so please provide us with a copy of your certificate. If not, are you interested in becoming certified? Yes_ No_ 18. What is your state/commonwealth Medicaid provider #? NA (If a Medicaid provider # has been assigned to your company) Page 3 of 5 AccessZCare 19. Insurance Information Insurance Company Limit Amount per occurrence/aggregate $ VEHICLES ARE LEASED TO OPERATIONS PROVIDER (contractor) SEE ATTACHED INSURBNCE CERTIFICATE Vehicle Liability Personal Liability Workman’s Comp NOTE: Attach insurance cover sheets or certificates of insurance to this application. 20. Have there ever been any liability (i.e., malpractice, commercial, or vehicle) claims, suits, judgments, settlements or arbitration proceedings brought against you or currently pending involving you? O Yes XJ No 21. Have you (or any employee that will provide services for us) ever been suspended, fined, disciplined, investigated, expelled, sanctioned or otherwise restricted or excluded from participation in any private, federal, or state health insurance programs (i.e., Medicare/ Medicaid), or are any such proceedings in progress against you/them? 0O Yes ¥ No 22. Have you (or any employee that will provide services for us) ever been disciplined or sanctioned by any professional licensing body or accrediting organization, or are any such proceedings in progress against you/them? O Yes X1 No 23. Have you (or any employee that will provide services for us) ever been convicted of, pled guilty to, or pled nolo contendere to any felony that is reasonably related to your qualifications, competence, functions or duties of the services that will be provided or currently under indictment or currently have pending any such charges? 0 Yes & No 24. Have you (or any employee that will provide services for us) ever been convicted of, pled guilty to, or pled nolo contrendere to any felony that alleged fraud, an act of violence, child abuse, patient abuse or sexual misconduct or are currently under indictment or currently have pending any such charges? O Yes X No For any of these questions that you answered Yes. please provide a full and complete explanation on an additional sheet of paper. Answering Yes to any of the above questions does not necessarily disqualify you from consideration. Page 4 of 5 Access?Care By signing this application, the Transportation Provider acknowledges that it, as well as any employee or contract employee, is not listed on the U.S. Department of Health and Human Services’ Excluded Provider list for federal health care programs. Under no circumstances shall any such excluded provider be allowed to provide services in our Network. APPLICANT’S SIGNATURE The undersigned Provider certifies that the above information is true and complete. [ further certify that the service specified above will operate in conformity to the requirements of all local, state, and federal regulations. The undersigned Provider hereby consents to its (including any of its principals or employees) background being checked by AMR and/or its agent. Providers consents to the disclosure, inspection and copying of information and documents related to Provider's qualifications for Network participation by and between AMR and other health care organizations and third parties regarding Provider's qualifications for the purpose of evaluating this application. Provider is informed and acknowledges that federal and state laws provide immunity protections to certain individuals and entities for their acts and/or communications made in good faith in connection with evaluating the qualifications of health care providers. Provider hereby releases all persons and entities, including AMR, their representatives and all persons and entities providing information to AMR, from any liability they might incur for their acts and/or communications in connection with evaluation of Provider's qualifications for Network participation, including any decision to admit or deny Provider's application. Provider understands and agrees that Provider, as an applicant, has the burden of producing adequate information for proper evaluation of Provider's qualifications for Network membership. The undersigned hereby affirms that the information submitted in this application and any addenda thereto is true, current, correct, and completed to the best of my knowledge and belief and is furnished in good faith. Provider agrees to provide AMR with any updated information in the event of any change in the information set forth in this application. Applicant Signature Date PLEASE CHECK THE FOLLOWING TO MAKE SURE YOU’VE SUBMITTED A COMPLETE APPLICATION: Have you completed all provider information? Have you attached a copy of your insurance coverage? Have you attached a copy of your business license? Did you sign the application? e e Page 5 of 5 Access 2Care Transportation Provider Contact Sheet Provider Name: Maruti Fleet & Management Physical Address: _600 Transit Way Physical City, State ZIP: Fort Walton Beach, FL 32547 Email address: rberkstresser@co.okaloosa.fl.us Dispatch Contact ; John Fick Billing Contact Name: Crystal Meyers Phone : 850-833-9168 Billing Contact Number: _850-833-9168 Fax: 850-833-9286 Billing Contact Fax: 850-833-9286 After hours contact Name: Bob Berkstresser, GM or Crystal Meyers, Asst GM After hours Number: _ (850) 238-2046 N ACORDr v CERTIFICATE OF LIABILITY INSURANCE MARUT-2 OP ID: A3 DATE (MM/DD/YYYY) 09/30/2015 THIS CERTIFICATE IS ISSUED AS A MATTER OF INFORMATION ONLY AND CONFERS NO RIGHTS UPON THE CERTIFICATE HOLDER. THIS CERTIFICATE DOES NOT AFFIRMATIVELY OR NEGATIVELY AMEND, EXTEND OR ALTER THE COVERAGE AFFORDED BY THE POLICIES BELOW. THIS CERTIFICATE OF INSURANCE DOES NOT CONSTITUTE A CONTRACT BETWEEN THE ISSUING INSURER(S), AUTHORIZED REPRESENTATIVE OR PRODUCER, AND THE CERTIFICATE HOLDER. IMPORTANT: If the certificate holder is an ADDITIONAL INSURED, the policy(ies) must be endorsed. If SUBROGATION IS WAIVED, subject to the terms and conditions of the policy, certain policies may require an endorsement. A statement on this certificate does not confer rights to the certificate holder in lieu of such endorsement(s). PRODUCER Cobbs Allen - Birmingham 115 Office Park Drive, Ste 200 Birmingham, AL 35223 William Failor CONIACT William Failor PHONE ); 205-414-8100 | FAX (A/C, No): ADDRESS: NAIC # INSURER(S) AFFORDING COVERAGE insurer A : Maxum Indemnity Company INSURED Maruti Fleet & Management, LLC wsurer 8 : Scottsdale Insurance Company 41297 Maruti Transit Group, LLC RLI 13056 4533 Highway Ave INSURER C : Jacksonville, FL 32254 nsurer o : Technology Insurance Co 42376 INSURERE : INSURERF : COVERAGES CERTIFICATE NUMBER: REVISION NUMBER: THIS IS TO CERTIFY THAT THE POLICIES OF INSURANCE LISTED BELOW HAVE BEEN ISSUED TO THE INSURED NAMED ABOVE FOR THE POLICY PERIOD INDICATED. NOTWITHSTANDING ANY REQUIREMENT, TERM OR CONDITION OF ANY CONTRACT OR OTHER DOCUMENT WITH RESPECT TO WHICH THIS CERTIFICATE MAY BE ISSUED OR