US Rehab Member Application

Fill out the form below, or print it out,
and fax it to 319-235-9774
Or, if you prefer, mail to

U.S. Rehab
P.O. Box 2878
Waterloo, IA 50704

Phone 800-987-7342
Contact: Jerry, Carrie, or Jay

Mailing Information
Company
DBA
Address
City, St (or Prov), Zip
Phone
Toll-Free
Medicare #
Medicaid #
Tax ID#
NPI#

Shipping Address
Address
City, St (or Prov), Zip

General Information
Is your fax machine on at night? Yes No
Fax
Owner's Name
Owner's SS#
Time Zone	Eastern Central Mountain Pacific
Contact Name

Internet Information
Email Address
URL of website

Branch Information
Do you have any branch stores? Yes No Number of stores
Branch 1 address
Store Manager
Phone
Fax

Branch 2 address
Store Manager
Phone
Fax

Branch 3 address
Store Manager
Phone
Fax

Branch 4 address
Store Manager
Phone
Fax

Number of Employees
Years in Business
Est. Annual Sales
Accounts payable contact person

Do you belong to other buying groups?	Yes No
Who?

Do you utilize a computer in your business?	Yes No
Does your company access the Internet from the office computer(s)?	Yes No
	If Yes: Bookmark our site: http://www.usrehab.com
Do you carry product liability insurance?	Yes No
With whom?
Contact Person For Insurance Concerns:

Do you use any type of equipment financing?	Yes No
With whom?
Financial Services Contact

Who is your long distance service carrier?
Telephone Service Contact

Catalog Information

Purchasing Agent
Catalog Shipping Address
City, St (or Prov), Zip

Number of Rehab Catalogs
* There is an additional charge for more than 1 set of catalogs, please call for details.

Revenue

What is your company's total annual revenue?		Less than $1.5 million $1.5 million to $2.5 million $2.5 million to $5 million $5 million +
What is your company's total annual rehab revenue?		Less than $500 K $500 K to 1 million $1 million to $2 million $2 million +
Please list all employees who are currently members of NRRTS and also those who are CRTS:

HOMELINK Information

Business Hours
24 Hour Phone	Yes No
Phone Number:
HOMELINK Contact Person
County
Are you accredited?	Yes No
By whom?	JCAHO CHAPS NARDS NRRTS Other
Date of survey?
Do you currently contract with HMOs and/or PPOs? Yes No
Payment remit address if different:

Do you have a repair center?	Yes No
If yes, how many technicians?

What products or services are you able to provide?

Product or Service	Brand most often used	Product or Service	Brand most often used
High tech wheelchairs		Liquid Oxygen
Electric wheelchairs		Price Per Pound	$
Manual wheelchairs		Price Per E-tank refill	$
Unit dose medications		Transfill on-site (gas)	Yes No
IV therapy		Do you swap tanks?	Yes No
Enteral nutrition		Apnea monitors
Seating & Positioning		CPMs
Bariatric		Lymphedema pumps
Ramps & Lifts		Wallaby
Van Conversions		Volume ventilators
Custom Rehab		Oxygen Concentrators
Hi-tech pediatric services		CPAP
Wound care		BiLevel
Beds		In-home sleep diagnostics
Low air loss therapy		Patient lifts
Patient supports		Orthotics
Braces		Prosthetics
Ostomy		Phototherapy
Colostomy		Home health agency
		Other

Do you have a post-mastectomy fitter on staff?	Yes No
	Full time Part time
What mastectomy products do you use?
Do you currently employ a physical, occupational, or speech therapist?	Yes No

How Can We Communicate With You?

At U.S. Rehab, we are dedicated to helping independent Rehab providers become more successful, and we believe communication is the foundation for mutually beneficial relationships.

We strive to ensure that all information we share with our family of providers goes to the individual who needs it. To help us achieve this goal, please fill out the following form.

Who in your office should receive information on these topics and what is the best way for us to send it?

	Name	Mail	Fax	Fax Number	Email Address
Pricing
Promotions
Industry News
Billing
Education

Comments

Please list any audits, investigations, citations, complaints, or claims filed, disputes or similar events during the past five years in connection with any vendor, customer, third-party insurer, professional organization or government agency, or any presently pending or threatened action or event of a similar nature:

Membership is dependent upon abiding by all U.S. Rehab Standards of Membership including:

Being responsible for timely payment to all U.S. Rehab Vendors and maintaining a current status with U.S. Rehab for Membership dues.
Agreeing to purchase a minimum of 75% of all products under U.S. Rehab Vendor Contracts.

By submission of this application, the applicant authorizes U.S. Rehab, Inc., or its agents to contact the vendors, banks, and others listed herein, as well as any state or federal agency and any credit reporting agency or business bureau to verify credit worthiness and business reputation of the applicant.

Provider's Name and Title Date

U.S. Rehab Associate Date