Provider Application

Company Officers & Control Personnel (10% ownership)

At least one (1) Company Contact is required.

Company Contact #1 Title*

Company Contact #1 Name*

First Last

Company Contact #1 Phone*

Company Contact #1 Email*

Add another Company Contact?

Yes
No

Company Contact #2 Title*

Company Contact #2 Name*

First Last

Company Contact #2 Phone*

Company Contact #2 Email*

Add another Company Contact?

Yes
No

Company Contact #3 Title*

Company Contact #3 Name*

First Last

Company Contact #3 Phone*

Company Contact #3 Email*

Service Specifications

Service Type*

BLS
ALS1
MICU
Wheelchair Van
Bariatric/Oversized Wheelchair Van
All Purpose Chair (Stretcher Van)
Med Car (sedans/vans used for ambulette trips)
Multi-Passanger Van (6+)
Air Flight

Select option(s)*

Fixed-Wing
Rotor-Wing

How Many Ambulances?

How Many Wheelchair Vans?

How Many Bariatric/Oversized Wheelchair Vans?

How Many All Purpose Chairs (Stretcher Vans)?

How Many Med Cars (sedans/vans used for ambulette trips)?

How Many Multi-Passanger Vans (5+)?

Multi-Passenger Van Capacity*

Please enter a number greater than or equal to 5.

List any special equipment*

What areas are you currently servicing?*

(Please be specific)

Hours of Operation

Monday-Friday OPEN*

: HH

MM

Monday-Friday CLOSE*

: HH

MM

Saturday OPEN

: HH

MM

Saturday CLOSE

: HH

MM

Sunday OPEN

: HH

MM

Sunday CLOSE

: HH

MM

Questions and Comments

Date Established*

What is your company advantage?*

Describe your hiring process for drivers and medics:*

List any special training and certifications that the company requires of their drivers/medics:*

(Please list all that apply - Enter 'None' if none)

Are your medics PALS ( Pediatric Adanced Life Support) certified?*

(Please list all that apply - Enter 'None' if none)

Do you do criminal background checks on company employees and contractors?*

Yes
No

Do you do drug testing on company employees and contractors?*

Yes
No

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?*

Yes
No

If you answered yes, please provide a full and complete explanation.*

(Answering Yes does not necessarily disqualify you from consideration.)

Have you (or any employees 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 program (for example Medicare or Medicaid) or are any such proceedings in progress against you?*

Yes
No

If you answered yes, please provide a full and complete explanation.*

(Answering Yes does not necessarily disqualify you from consideration.)

Have you (or any employee that will provide services for us) ever been convicted of, pled guilty to, or pled nolo contender 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 such charges?*

Yes
No

If you answered yes, please provide a full and complete explanation.*

(Answering Yes does not necessarily disqualify you from consideration.)

Have you (or any employee that will provide services for us) ever been convicted of, pled guilty to, or pled nolo contender 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 such charges?*

Yes
No

If you answered yes, please provide a full and complete explanation.*

(Answering Yes does not necessarily disqualify you from consideration.)

Does your business qualify for your State’s “Minority-Owned Business Enterprise”(MBE)?*

(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% 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.)

Yes
No

If yes, is your company a Certified MBE?*

Yes
No

Does your business qualify for your State’s “Women-Owned Business Enterprise”(WBE)?*

(Note: This designation is not available in all states. The description is as above, replacing “women” for “minority”)

Yes
No

If yes, is your company a Certified WBE?*

Yes
No

Are you currently authorized to bill Medicare?*

Yes
No

Are you currently authorized to bill Medicaid?*

Yes
No

Additional Comments

Applicant Information

Applicant's Name*

First Last

Applicant's Title*

Applicant's Phone*

Applicant's Email*

Signature

Your Name*

First Last

Today's Date*

Acceptance of Terms*

Your acceptance of these terms is required to submit your application. Check the box to agree.

By checking this box, I certify that the submitted information is true, current, correct, and completed to the best of my knowledge and belief and is furnished in good faith. I further certify that the service described in this application will operate in conformity to the requirements of all local, state, and federal laws and regulations.

GDPR Personal Data Consent*

Your acceptance of these terms is required to submit your application. Check the box to agree.

By checking this box, you are confirming that you understand the purpose of this form is to primarily allow end-users to contact Land-Air Medical for legitimate business purposes and that you may request to have Land-Air Medical obliterate your data records completely by contacting us via this form. We never sell any data to any third-party data aggregators.

What is 8 + 2?*

Please solve for the Submit button to appear.

Company Information

Company Officers & Control Personnel (10% ownership)

Service Specifications

Hours of Operation

Questions and Comments

Applicant Information

Signature