Contact Us - Provider Registration Form

Provider Information

Name*

First Last

Company Name/Name of Practice:*

Address*

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

Phone*

Email*

Insurance Accepted*

Credentials*

Licensing Body*

License Number*

Do you offer Video/Virtual options through a secure site.*

Yes
No

How did you hear about Hope Works Here?*

Rates

I accept the following pre-negotiate rates:*

Select All
First affected employee visit at providers office: $175
Provider visit to affected employee's workplace/employer: $250
Second affected employee visit at providers office: $175

Area of Expertise

Areas of Expertise/specialty related to child loss or medically complex condition (check all that apply):*

Agreement

Agreement Terms: Please write your name if you agree to the following terms below.*

Client referrals: Provider understands that registration in the Hope Works program is voluntary and does not guarantee client referrals. Client referrals are at the discretion of Faith’s Lodge. Provider agrees to respond “accept” or “decline” within 24 hours of a referral to ensure the client needs are addressed in a timely manner. Payment: Provider agrees to provide proof of performance and/or invoice to get paid for any visits. Release of Liability: Provider agrees to provide and maintain liability insurance coverage for their practice and will provide proof of insurance to Faith’s Lodge. Provider agrees to also list and identify Faith’s Lodge as an “Additional Insured” on Providers insurance policy. Provider will adhere to the ethical standards outlined by their credentialing organization. Faith’s Lodge, the bereaved employee, the employer or any of their affiliates are not liable for any misconduct of a grieving parent in session. Provider releases Faith’s Lodge from all liability related to the program, and agrees to defend and indemnify Faith’s Lodge from any claims or damages arising from Provider’s acts or omissions. Non-Compete: Provider agrees that it is not an employee or agent of Faith’s Lodge. Provider agrees to not offer competing service while registered as a provider for the Hope Works program and for at least five (5) years following disengagement from the program.

A Hope Works Here staff member will follow up with you within 2 business days.

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