C.A.R.E.S. Preferred Partners Application

Organization Name*

Years in Business*

Phone*

Email Address*

Address*

Street Address City State / Province / Region ZIP / Postal Code

Website

Referred By (if applicable)

Primary Service Provided:*

Who Do We Contact? (Can be the same person) Please fill out completely.

Referrals / Communications*

First Last

Title*

Phone

Email

Marketing / Promotions*

First Last

Title*

Phone

Email

Billing / Invoices*

First Last

Title*

Phone

Email

Please fill out completely.

1. What interests you most about the Preferred Partners Program?*

2. Do you currently have a relationship with Benevilla or other non-profit organization(s)? If so, please explain in detail.*

3. Please provide us with your organization's Mission Statement, Vision and Core Values.*

4. (Facilities and Hospice Only) Please attach your organization's most recent state survey. It must be no older than 3 years.

Drop files here or

5. Is your company part of any other industry membership(s) or partnership(s)?*

6. Please explain in detail how your organization is giving back to the community in terms of education, volunteering, assistance or support.*

7. How does your organization encourage diversity, inclusivity, and cultural awareness?

8. Do you require staff to have a Level 1 Fingerprint Clearance Card?*

Yes
No

9. What do you feel your organization brings to our partnership and what do you think sets you apart from others in your category?*

10. If approved for the partnership program , on a scale from 1-10 (1=minimal participation and 10 = maximum participation) how would you gauge your level of anticipated participation in the program? (Examples: Attending monthly partner meetings, responding to communications, event participation, etc.) Please explain.*

11. (Non-Medical Home Care Applicants Only) Are you a current member of the Arizona In Home Care Association (AZNHA)?*

Yes
No

12. How does your organization address complaints or concerns regarding the services you provide or your quality of care?*

13. Please provide a detailed example of how your organization exemplifies person-centered care.*

Please provide three professional references.

Full Name*

First Last

Relationship*

Company*

Phone*

Address*

Email*

Full Name*

First Last

Relationship*

Company*

Phone

Address*

Email

Full Name*

First Last

Relationship*

Company*

Phone

Address*

Email

Disclaimer and Signature

I certify my answers are true and complete to the best of my knowledge. If this application leads to program acceptance, I fully understand false or misleading information in my application may result in removal from the program with no refund of monies paid.

Signature*

Date*

Consent*

I agree to the Benevilla Privacy Policy as stated on our website.